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Date run 7/5/2017 2:41:26PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Run by Report A5021 <br /> Facility Information as of 7/5/2017 P�a1 <br /> Record selecfon Crderia: FacilityID FA0015131 <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 <br /> SSN/Fed Tax ID <br /> Owner ID OW0008258 New Owner ID <br /> Owner Name ZARZOZA LUCID, SERGIO <br /> Owner DBA AUTOMECANICA QUALITY SERVICE <br /> Owner Address 1852 W ELEVENTH ST 259 <br /> TRACY, CA 95376 <br /> Home Phone 209-605-8997 <br /> WorkBusiness Phone 209-855-1016 <br /> Mailing Address 1852 W ELEVENTH ST#259 <br /> TRACY, CA 95376 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0015131 <br /> Facility Name AUTOMECANICA QUALITY SERVICE <br /> Location 23737 S CHRISMAN RD <br /> TRACY, CA 95376 <br /> Phone 209-855-1016 x0 <br /> Mailing Address 1852 W ELEVENTH ST#259 <br /> TRACY, CA 95376 <br /> Care of SERGIO ZARZOZA LUCIO <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 005- ELLIOTT, BOB Fax <br /> APN 25014013 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 AR0025956 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name AUTOMECANICA QUALITY SERVICE (Circle One) <br /> Account Balance as of 7/5/2 00 i�n/c ZO/ t Al 6'^s;6.45 2o/7 <br /> /Q,— f (Circle 0.) <br /> Program/Element and Description Record ITD <br /> —(Q,-5r <br /> ID and Name Stews <br /> TransferOwn to Active fete <br /> New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO522281 EE0000009-NICHOLAS LOEHRER Inactive Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PR0522209 EE0000016-BETTY HO Active Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534229 Inactive Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSrEHD 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 andor Standards and State andor <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, <br /> �7 <br /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />