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ERecord <br /> 12/2312016 8:57:20# SAN ,IOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Report*5021 <br /> Facility Information as of 12/23/2016 Pagel <br /> ection Criteria: Fatality ID FA0023806 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID OW0022174 New Owner ID <br /> Owner Name Lithia Motors <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 541-776-6401 <br /> Mailing Address 150 N Bartlett St <br /> Medford, OR 97501 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0023806 10720657 <br /> Facility Name Volkswagen of Stockton <br /> Location 3055 B Hammer Ln <br /> Stockton, CA 95212 <br /> Phone 209-242-9680 x <br /> Mailing Address 1020 S Beckman Rd <br /> Lodi, CA 95240 <br /> Care of Dawn Branham <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 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 AR0044086 New Account ID: <br /> Mail Invoices to Account Mail Invoices to Owner / Facility / Account <br /> Account Name Volkswagen of Stockton (Circle One) <br /> Account Balance as of 12123/2016: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status <br /> New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PRO541526 EE0008709-JAMIE LIMA Active Y N A I D <br /> 2220-SM HW GEN <5 TONSIYR PRO541525 EE0000005-FATINAH ZAREEF Active 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.PHSIEHD 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 andlor Standards and State andYor <br /> FederaQ Laws. <br /> APPLICANT'S SIGNATURE Date I ! <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date 1 f <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: 62a&a /j/? Date /-7- _/ 10 Account out: Z-f� Date�I�1 r 4- <br /> COMMENTS: <br /> COMMENTS: U <br /> Invoice <br /> #' <br /> Ce,ill SI�bmVf-rpt ( ��-/E�f1.2 <br /> t3 ill q Ulm <br />