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Daie run 3/24/2010 12:26:54PI SAN JC JUIN COUNTY ENVIRONMENTAL HEA 'R DEPARTMENT <br />Repo" #5021 <br />Run by 11 �./2 <br />Facility Information as of 3/24/2010 <br />Pagel <br />RecoN Selection Cdteha Facility ID FA0015569 <br />Make changes/corrections in RED ink. <br />f C INFORMATION CHANGE(dale) <br />���.• C OWNERSHIP CHANGE(date) <br />OWNER FILE INFORMATION �.,..,..�,�,�.. SSN / Fed Tax ID <br />Owner ID OW 0012518 New Owner ID <br />Owner Name SALAZARS QUALITY TRUCK WORKS <br />Owner DBA SALAZAR'S QUALITY TRUCK WORKS <br />Owner Address 4720 CAYMAN CT <br />STOCKTON, CA 95210 <br />Home Phone Not Specified <br />Work/Business Phone 209-466-4090 <br />Mailing Address PO BOX 8236 <br />STOCKTON, CA 952080236 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID FA0015569 <br />Facility Name SALAZARS QUALITY TRUCK WORKS <br />Location 1622 E ALPINE AVE / !.S f E . 4t r^ E✓E <br />STOCKTON, CA 952052525 <br />Phone 209-466-4090 x0 <br />Mailing Address PO BOX 8236 <br />STOCKTON, CA 952080236 <br />Care of <br />Location Code 99 - UNINCORPORATED P Alt Phone <br />BOIS District 002 - RUHSTALLER, LARRY Fax <br />APN EMail : <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0026869 New Account ID <br />Mail Invoices to Facility Mail Invoices to: Owner / Facility <br />/ Account <br />Account Name SALAZARS QUALITY TRUCK WORKS (Circle One) <br />Account Balance as of 3/24/2010: $262.00 <br />(circ. One) <br />Transfer <br />to Acbve/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br />2220 - SM HW GEN <5 TONS/YR PR0523833 EE0004636 - GARRETT BACKUS Active Y <br />N A 1 D <br />2244 - PACT TRANSFER RECORD - OES PR0523433 EE0000000 - HAZ MAT SJC OES Inactive Y <br />N A I D <br />3122 - STORMWATER INSPECTION - AUTO SHOP PRO523068 EE0004636 - GARRETT BACKUS Active Y <br />N A I D <br />ERSC - ELECTRONIC REPORTING SURCHARGE PRO533757 Active Y <br />N A I D <br />BILLING and COMPLIANCE ACI(NOWLEDGEMENT: I, Me undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this <br />facility or activity will be billed to Me party identified as the OWNER on this form . I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and /or Standards end <br />State and/or Federal Laws. <br />APPLICANT'S SIGNATURE: Lam(/h, / Date_/�/� <br />Program Records to be TRANSFERED: " $$220.00 = Amount Paid Date <br />Water System to be TRANSFERED: ' $372.00 = Amount Paid Date <br />Payment Type Check Number Received by <br />REHS: Date Account out: _�� Date 10 <br />'x/10 <br />COMMENTS: <br />NC-�j pi-jjZ£ss <br />\\eh-env\envision\reports\5021. rpt <br />