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Deremn 626/2017 425:30PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Repaftk5021 <br /> Runes Pagel <br /> Facility Information as of 6/26/2017 <br /> Record eelxean c'ta,ia; Emily I0 FA0013644 <br /> Make changea/correctlons In RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner to OW0010757 New Ownr ID : <br /> Owner Name BRAVO,ANDRES 1(` a tn�(A (� �t <br /> Owner DBA BRAVO BROS AUTO BODY OwnerAddress 5174 E KETTLEMAN LN 2M1�9_ <br /> A 0A <br /> LODI, CA 95240 <br /> Home Phone 209-475-2236 -7 7_rL 1ii <br /> Work/Susiness Phone Not Specified h c) <br /> MailingAddress _.n- ,— <br /> 5174 E KETTLEMAN LN � n�¢ 1� rr�E�l•� <br /> LODI, CA 95240 <br /> care of BRAVO,ANDRES <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0013644 10184485 <br /> Facility Name BRAVO BROS AUTO BODY p �ylyq .7 e.�gnLe <br /> Location 720 E LODI AVE 0-' t SManr'� <br /> LODI, CA 95240 obi yT_��'2, <br /> Phone 209-475-2236 T'1 <br /> Mailing Address 720 E LODI AVE �(✓. <br /> LODI, CA 95240 - f 0 1 4 <br /> care of BRAVO,ANDRES <br /> Location Cade 02-LODI Alt Phone <br /> SOS District 004-WINN, CHARLES Fax <br /> APN 04745013 Email: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION { <br /> Contact Name S l I t,,`+/ <br /> Title <br /> Day Phone ..!' <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022800 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner I Facility / Account <br /> Account Name BRAVO BROS AUTO BODY (times»! <br /> Account Balance as of 6/2612017: $0.00 <br /> (Glade Oral <br /> PrearemHemmteM Oeemptian Remrd ID Em*yee lO and Nemo staN. New Owr,er? ONIW Na <br /> 1920-HMBP-Common Materials PR0521048 EE0008709-JAMIE LIMA Active Y N AI D <br /> 2220-SM HW GEN<5 TONS/YR PRO517990 EE9999998-ONE VACANTI Active Y N A D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO517991 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO517992 EE0000000-HAZ MAT SJC DES InaeWe Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532277 Inactive Y N A 1 D <br /> ,x Ra e00 babAW 1JJCEACKNOWLEDGEMENT:Nen rri ft lybd Owner,Operebn ar aga�lMsame,eckrxrweadae setWsYe,uWar pmfec!Spm Ik.PNS�ENO tgWydiegea MCObawErM eYa feWly <br /> a acOullY rra be bile0lo Ne party idantiRetl as Ne OWNER nn N4 kmi I rias mrWy Nat all operetlorrc wa ha performed In accaraena wtN aA epperade Ordlv,n C04w erWor StaMa,ds a,d State eneor <br /> FedarN lewf. �//� <br /> APPLICANTS SIGNATURE: Date 1 L'V <br /> Program Records to be TRANSFERED: •$26.00= Amount Paid Date_/_/_ <br /> Water System to be TRANSFERED: Amount Paid Date—/ /_ <br /> Payment Type Check Number Received <br /> EHD Sten: Dete. _/ / _ Account out: Dana -7l� 7 <br /> COMMENTS'. InvoicelF: 99507 <br /> �Jr1rwrti. A5 2Z-Z_D' <br />