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Date run 2/912007 11:23:36AM <br /> Rugby SAN JO' -'JIN COUNTY ENVIRONMENTAL HEAL 'DEPARTMENT Report#5021 <br /> Facility Information as of 2/9/2007 Pagel <br /> Record Selection Criteria: Facility ID FAGO15499 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0012452 New Owner ID <br /> Owner Name VICTOR BEJARANO <br /> Owner DBA V&S MOBILE TRUCK REPAIR <br /> Owner Address 474 S AURORA ST <br /> STOCKTON, CA 95203 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-466-W4 ; 5 <br /> Mailing Address 474 S AURORA ST <br /> STOCKTON, CA 95203 <br /> pp Care of <br /> `JFA ITY FILE INFORMATION <br /> Facility ID FA0015499 <br /> Facility Name V&S MOBILE TRUCK REPAIR e�o' <br /> Location 474 S AURORA ST <br /> STOCKTON, CA 95203 IV� ,U 0� <br /> Phone 209-465-1664 Q <br /> Mailing Address 474 S AURORA ST O <br /> STOCKTON, CA 95203 <br /> N Care of C/ <br /> Location Code 01 -STOCKTON APN: <br /> BOS District 001 -GUTIERREZ, STEVE SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026741 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name V&S MOBILE TRUCK REPAIR (Circle one) <br /> Account Balance as of 2/9/2007: $19250 Sti v <br /> .t 11•�O\ (Circle One) <br /> Transfer to Active/Inadve <br /> Program/Element and Description Record IO Employee ID and Name Status New Ovmer? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0524403 EE0009155-TOUA YANG ive Y N A D <br /> 2244-PACT TRANSFER RECORD-OES PR0522728 EE0000000-HAZ MAT SJC OES t •��13 Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknovAedge that all e,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or ad"will be billed to the party identified as the OWNER on this hung. I also certify that all operations will be part in acmMance AM all applicable OMinace Colles and/or Standards and <br /> Stale anNor Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= mount Paid Date <br /> Water System to be TRANSFERED: `$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: L/ 16 Date I Account out: �Lr.� Date to ��/may i�� l-� <br /> COMMENTS: I 1 r iJi p �G LCI wT 1 3 W-i ' BV v I <br /> C.Ar> <br /> \\phs-ehsql-ntlapps\envisions\reports\5021.rpt ,` <br />