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Date run 4/20/2015 11:05:01AI SAN JO, JIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by — Pagel <br /> Facility Information as of 4/20/2015 <br /> Record Selection Criteria: Facility ID FA001 1268 <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 : 1 SSN/Fed Tax ID <br /> Owner ID OW0009268 Case Number: H09543 New Owner ID : <br /> Owner Name LESHER, GARY - <br /> Owner DBA DON'S MUFFLER & BRAKE SVC <br /> Owner Address 26 N CHEROKEE-L-N <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 299_334-29©2- — Z2 <br /> Mailing Address -P()-E(0X-9,¢-&3-- <br /> -tQ� 5241 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0011268 10184133 <br /> Facility Name DONS MUFFLER & BRAKE SVC ri5YY1 iSSt( S <br /> Location 26 N CHEROKEE LN A <br /> LODI, CA 95240 <br /> Phone-209-334-2902 x <br /> Mailing Address-ff&-g@j(-1433 7i <br /> +- B , A 95241 <br /> Care of AGefy-Lestler Man a�a Dan 05+orir-ro <br /> Location Code 02 - LODI Alt Phone <br /> BOIS District 004 -WINN, CHARLES Fax <br /> APN 04321027 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0018268 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name LESHER, GARY (Circle One) <br /> Account Balance as of 4/20/2015: $0.00 O2 0-z-(D (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0520794 EE0008709-JAMIE DE LA ROSA InactivE Y N I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513556 EE0000000-HAZ MAT SJC OES InactivE Y N I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0511268 EE000o000-HAZ MAT SJC OES InactivE Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532333 InactivE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent of sameacknowledge that all site.and/or project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the pany identified as the OWNER on this form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE. Date <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 by r� <br /> RENS: ge Date /��/ _ Account out: Date <br /> COMMENTS: <br />