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DEPARTMENT Report#5021 <br /> Data ren 21312016 11:52:43AM SAN J0. 71N COUNTY ENVIRONMENTAL HEAI� Paget <br /> R,-by = Facility Information as of 2/3/2016 <br /> Record Selection Criteria: Facility ID FA0020015 Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) I— 2 — <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN/Fed Tax ID <br /> Owner ID OW0016428 New Owner ID <br /> Owner Name �Ett, <br /> Owner DBA <br /> Owner Address �'$8' $ ' <br /> Home Phone .269-7 77-6045-? �9 <br /> Work/BusinessPhone 7¢Q-854-1f74- Zir.`� 2=2`4 9 g2 <br /> Mailing Address Pe-Bt9 �� u -L' l / - - Dl� <br /> r t� <br /> Care of WWQli E' I ''°i <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0020015 10187487 <br /> Facility Name <br /> Location 13336 E HWl'88 <br /> LOCKEFORD, CA 95237 <br /> Phone 2Gq-7 7q 5045-1t 79--z2 Lt GJ SF b ez) <br /> Mailing Address Pe-BG)A 929-- -Tt,--I9 <br /> IOjILF_F_pRB-G�?�7 `T�--^-� <br /> Care of �L 'g i/ / t-k Y745 <br /> Location Code 99 - UNINCORPORATED A Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN 01902044 EMaii: CAR <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION �y <br /> Contact Name "NIG E-1. <br /> Title <br /> Day Phone 209.757 645- v� _c 9 - Ch/ 576 g <br /> Night Phone VW <br /> ACCOUNTS RECEIVABLE FILE INFORMATION - onp\" D� <br /> Account ID AR0035640 `t 'Y New Account ID: <br /> Mail Invoices to Account /MS ID Mail Invoices to: Owner / Facility / Account <br /> Account Name J AND H SMOG ND REPAIR (Circle One) <br /> Account Balance as of 2/3/2016: $709.00 <br /> (Circle One) <br /> Transfer to Activelinactve <br /> Program/Element and Description Record ID Employee ID and Name Status eco Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0536729 EE0001422-ARIS VELOSO Active N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO531048 EE0002620-ALFONSO ARAMBULA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0536730 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHS/EHD 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 ander Standards and State ands <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date / I <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 /> EHD Staff: Date -7:7 / Account out: Date 2 / Z40 1 <br /> COMMENTS: <br /> IRVOICe#: <br />