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Run by : SANDY San Joaquin County PHS/EHD Report #5021 <br /> FACILITY INFORMATION as of 06/24/99 <br /> _ _ _ _ _ _ _ __ _ _ _____________________________9__ ----------- <br /> Make than ee/correcti a d� q encil: <br /> ORNER FILE INFORMATION INFORMATION CHANGE (date) : J <br /> OWNERSHIP CHANGE (date) : <br /> OWNER ID: 008605 CASE # : H08398 New owner ID: 00 <br /> Owner Name: DANIEL N CUEVAS <br /> owner DBA: <br /> Owner Address: <br /> i <br /> Home Phone: <br /> Soc Sec# / Tax ID#: <br /> Ownership Type: 02 INDIVIDUAL <br /> Mailing Address: 200 S CHEROKEE LN #B <br /> Care of: <br /> LODI, CA 95240 <br /> FACILITY FILE INFORMATION (�.l <br /> FACILITY ID: 010605 <br /> Facility Name: CUEVAS AUTO REPAIR <br /> Location: 200 S CHEROKEE LN B <br /> LODI 95240- 20 <br /> Phone: 209-333-060O�Call4+ tpaK- <br /> p�a�n�tbc� <br /> Mailing Address: 200 S CHEROKEE LN B <br /> Care of: MIKE TORRENTE �L <br /> LODI, CA 95240 <br /> Location Code: 02 APN: 043-230-23 <br /> BOS District: 004 SIC Code: 7538 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0017605 New Account ID: 000 <br /> Mail Invoices to: Account a nvoices to: Owner Facility / Account <br /> Account Name: CUEVAS AUTO PAIR /�(Iy ���y (Circle one) <br /> Account Balance as of 06/24/99 • $128 . 50 QM,�1 � (Circle ) <br /> Record UST(s) Transfer to Activat / Inactivate <br /> P/E Description Employee Statue Linked new owner? De to <br /> _______________________________________________________________________________ <br /> 2399 UNIFIED PROGRAM FAC STATE SERV PR510605 0000 SJC OES ACTIVE Y N A I D <br /> 2224 HAZ MAT BUSINESS PLAN AUTHORIZ PR512893 0000 SJC DES ACTIVE Y N A I D <br /> 2220 SM HW GEN <5 TONS/YR PR514385 0000 SJC DES ACTIVE Y N A I D <br /> ------------------------------------------------------------------------------- <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. I also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> ______________________ -_-_____________ ______________-______ <br /> vPR Records to be TRANSFERED: x $20.00 = Amount Paid Date_/ / <br /> Water System to be TRANSFERED: x $150.00 = Amount Paid Date—/— <br /> -------Payment Type Check # _ Recvd by <br /> --------------------------------------- <br /> ________________ -___________ -- •^�Sy`�/_ ___________________ <br /> RENS or COUNTER SUPV: Date_/_/ ACCT out: Date /// ' / UNIT/File:_/_/_ <br />