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Date run 7/202015 12:41:28PI SAN JOe PIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report 05021 <br /> Run by Facility Information as of 7/20/2015 Pagel <br /> Record Selection Criteria: Facility ID FA0016202 <br /> Make changes/corrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br /> Owner ID OW0005820 New Owner ID <br /> Owner Name Big Valley Ford Inc <br /> Owner DBA <br /> Owner Address 3282 AUTO CENTER CIR <br /> STOCKTON, CA 95212 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-870-4427 <br /> Mailing Address 7120 Lincoln Oaks Rd <br /> Stockton, CA 95207 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0016202 10185111 <br /> Facility Name BIG VALLEY FORD LINCOLN <br /> Location 2929 AUTO CENTER CIR <br /> STOCKTON, CA 95212 <br /> Phone 209-870-4427 x <br /> Mailing Address PO BOX 690398 <br /> STOCKTON, CA 95212 <br /> Care of Darlene J Gibbons <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002-MILLER, KATHERINE Fax <br /> APN 12802019 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFOR TION <br /> Account" AR0028 5 New Account ID: : <br /> Mail Invoices to ACCOU Mail Invoices to: Owner / Facility I Account <br /> Account Name BIG ALLEY FORD LINCOLN (Circle One) <br /> Account Balance as of 7/20/2 5: $0.00 <br /> (Circle One) <br /> Tmnsfarto A.We0nactve <br /> ProgramfElement and Description Record 10 Employee ID and Name Status New Owne? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO524111 EE0000006-HAZA SAEED Active Y N AD <br /> 2227-GEN 5<25 TONS PERMIT PRO527711 EE0000005-FATINAH ZAREEF Active Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0528282 EE0000005-FATINAH ZAREEF Inactivf Y N AJ—�D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO527170 EE0004680-NATALIA SUBBOTNIKOVA Active Y N A ( I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO536036 Inactivc Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andor project spacifc,PH&EHD hourly charges associated with this facility <br /> or activity will be billed to the party Identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and Stale andor <br /> Federal Laws. ''^^ /� <br /> 3 <br /> APPLICANTSSIGNATURE:� IM&jn � � Date /_LIAO. <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received n <br /> EHD Staff: Date I / Account out: Date <br /> COM�MEEJWS: -kLI ,y," <br /> 5 <br /> III Invoice#: <br /> 1 (1,0 ��C1a2.r It(1 bu.St�CSS <br />