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Date run 10/4/2013 2:39:56PR SAN JUIN COUNTY ENVIRONMENTAL HEAW DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/4/2013 <br /> Record Selection Criteria: Facility ID FA0019100 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) [n -.2J- <br /> OWNERSHIP CHANGE(date) /0 - 0/-0 <br /> OWNER FILE INFORMATION //.. /I,^,�^. SSN/Fed Tax ID : <br /> Owner ID O 534 0✓�15137 New Owner ID : h <br /> Owner Name TOCKTON NISSAN <br /> Owner DBA STOCKTON NISSAN Q Y4,5LCn orS n✓ <br /> Owner Address 3077 E HAMMER LN <br /> STOCKTON, CA 95212 7 G K L Ut <br /> Home Phone 209-956-1930P.L /{jn /a- <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 691180 <br /> STOCKTON, CA 952691180 C!/ 1 n4 (y Kf• SfJlY16 <br /> Care of <br /> FACH,ITY FILE INFORMATION �, ( <br /> Facility ID I CERS ID FA0019100 10,187,055 Lithia (J-t- S4 -li <br /> Facility Name STOCKTON NISSAN <br /> Location 3077 E HAMMER LN3077 <br /> STOCKTON, CA 95212 -UX <br /> Phone 209-956-6500 Gat" (456 - &5106 <br /> Mailing Address PO BOX 691180 <br /> STOCKTON, CA 952691180 i/` /yt.V 0701CYJ - ME <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax Q60 itil e(os <br /> APN 12618019 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION n <br /> Contact Name /� O/l <br /> Title <br /> Day Phone <br /> Night Phone � [ <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0034013 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name STOCKTON NISSAN (Circle One) <br /> Account Balance as of 10/4/2013: $0.00 <br /> (Circle One) <br /> PragraMElement and Description Recortl ID Em to ID and Name Transfer to Active4nactve <br /> Employee Status N Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0528772 EE0006044-LOWELL ALLEN Active Y N A I D <br /> 2227-GEN 5<25 TONS PERMIT PRO528320 EE0004636-GARRETT BACKUS Active Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PR0528319 EE0004636-GARRETT BACKUS Active,l Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO528247 EE0002620-ALFONSO ARAMBULA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533074 Inactivc Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: t,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charg associated with thisfacility <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 endor Standards and State ander <br /> Federal Laws. <br /> 1 <br /> APPLICANT'S SIGNATURE: JA Date 1 C) /0-a / <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 /> REHS: Date�L/ /J,� Account out: `5��(J�— Date <br /> COMMENT <br /> 2v(L-- iIIIzI13 <br />