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Date run 10/27/2003 10:31:501 SAN J""T COUNTY ENVIRONMENTAL REAPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1012712 a; 1 <br /> mA <br /> r, )f u n <br /> Record Selection Criteria: Facility ID FA0004959 <br /> Make changeslcorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0003859 New Owner ID <br /> Owner Name OCAMPO, ALFONSO 44"t 4"u- . <br /> Owner DBA JEt5rsAUTQMQTIVSCH'A1 <br /> Owner Address , <br /> Home Phone Not Specified <br /> Work/Business Phone 209-469-7116 <br /> Mailing Address 930 E CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Care of _ OVA—ALM <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0004959 <br /> Facility Name JERRY'S AUTOMOTIVE 0&4 �25)YIS <br /> Location 930 E CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Phone 209-469-7116 [_ O��Zit L(p -A 39-7 T_ <br /> Mailing Address 930 E CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Care of <br /> Location Code 01 -STOCKTON APN:16718305 <br /> BOS District 001 -GUTIERREZ, STEVE SIC Code:99Q0 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION faV* <br /> Account ID AR0005401D paa� New Account ID: <br /> Mail Invoices to Facility r Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name JERRY'S A TIVE (Circle One) <br /> Account Balance as of 10/27/2003 928.50 ' <br /> (Circle One) <br /> Transfer Active/Inactve <br /> Program/Element and Description.: Record ID Employee ID and Name Status New Droner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0517682 EE0008844-DINA ABATE Active Y N I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0517681 EED000008-LETITIA BRIGGS Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0521105 EE0000000-HAZ MAT SJC OES Active Y N A D <br /> 2381 -UST FACILITY(BEFORE 1184) PR0500994 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0517683 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: i,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity wilt 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / 1 <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date 1 I <br /> Water System to be TRANSFERED: *$155-00= Amount Paid Date / 1 <br /> Payment Type Check Number Received b <br /> REHS: Date 1 I Account out: Date /0 0 3 <br /> COMMENTS: <br /> IIPhs-ehsgl-ntlappslEnvisionslReports15021.rpt <br />