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Date run 12/21/2017 8:03:43A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/21/2017 <br /> Record Selection Criteria: Facility ID FA0018649 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN 1 Fed Tax ID <br /> Owner ID OW0015326 New Owner ID <br /> Owner Name Willard Wayne <br /> Owner DBA WAYNE MOTOR CO <br /> OwnerAddress 1675 W CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-464-5299 <br /> Mailing Address 1675 West Charter Way <br /> Stockton, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0018649 10409374 <br /> Facility Name Wayne Motor Company <br /> Location 1675 W Charter Way <br /> Stockton, CA 95206 <br /> Phone 209-464-5299 x <br /> Mailing Address 1675 West Charter Way <br /> Stockton, CA 95206 <br /> Care of Willard Wayne <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 163-370-10 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 AR0033014 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner I Facility 1 Account <br /> Account Name Willard Wayne ( (Circle One) <br /> Account Balance as of 1212112017: 9.01 �. <br /> (Circle One) <br /> Transfer to Activeflnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status IN nw—P Delete <br /> 1921 -HMBP-Regular-Primary Location PR0527518✓ EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN t5 TONS[YR PR0538454 EE0000026-CESAR RUVALCABA Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO535707 EE0009000-HARPRIT MATTU Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO533189 InactivE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PH5IEHD hourly charges associated with this <br /> facility 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 anti Standards <br /> and State ani Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date ! 1 <br /> Water System to be TRANSFERED: Amount Paid Date i 1 <br /> Payment Type Check Number Received y <br /> EHDStaff: Date / 11 1 17 Accountout: Date 1 .2-1 1 <br /> COMMENTS: / Invoice#: <br /> rc r fC7 C , <br />