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Date run 3/12/2018 8:29:04AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/12/2018 <br /> Record Selection Cdterla Facility ID FA0010162 <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 1 Fed Tax ID <br /> Owner ID OW0008162 Case Number: H06985 NOwner ID : <br /> Owner Name f � <br /> Owner DBA <br /> OWnerAddress _-rm61 nr ItETR IRyr tar - vp <br /> ywcc <br /> Home Phon _ LALV <br /> Work/Business Phone G. )� 1- 1191 <br /> Mailing Address 2953 CHERRYLAND AVE#B <br /> STOCKTON, CA 952152233 _ <br /> Care o i <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0010162 10183281 <br /> Facility Name <br /> Location 2953 CHERRYLAND AVE STE B <br /> STOCKTON, CA 95215 <br /> Phone 209-931-1170 <br /> Mailing Address 2953 CHERRYLAND AVE STE B <br /> STOCKTON, CA 952152233 <br /> Care of 4AQ TIN WA9& <br /> Location Code 99 - UNINCORPORATED A Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 08710046 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name Wade artrt n l Man, . <br /> , <br /> Title Owner �nl' <br /> Day Phone <br /> Night Phone-24q_g&9_7+7-8 -+ <br /> ACCOUNTS RECEIVABLE FILE INFORMATION _ `( ,`Ell <br /> Account ID AR0017162 �, New Account ID: . <br /> Mail Invoices to Account V p'Q Mail Invoices to: Owner ! Facility / Account <br /> Account Name OFF ROAD E RPRISES V (Circle One) <br /> Account Balance as of 3/12/2018: $8, 9.15li ` <br /> �� (Circle One) <br /> y Transfer to Activelliractve <br /> gramlElement and Description Re r ID Employee ID and Name Status New Owner? Delete <br /> �� 4192 -HMBP-Req ular-Primary Locatior(� PR0520111 EE0008709-JAMIE LIMA Active Y N A I D <br /> ,0.22U"SM HW GEN<5 TONSIYR PRO514207 EE0000031 -ELIANNA FLORIDO Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512450 EED000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FE PR0510162 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 3122-STORMWATER INSPECTION-AUTO SHOP PR0522965 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE PR0532890 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PMSlEHD 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 andfer Standards and State and or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I ! <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date I 1 <br /> Water System to be TRANSFERED: Amount Paid Date I 1 <br /> Payment Ty e, Check Number Received rejDate <br /> EHD Staff: A:, Date 1 ' I Account out: 1� 1 >✓ p <br /> C MMENTS: <br /> ��'W } Invoice#: 3 o 5 f 2-7( <br />