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Date run 12/1/2014 10:43:07AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Repos u5o21 <br /> Run by Paget <br /> Facility Information as of 12/1/2014 <br /> Record Selection Criteria: Facility ID FA0009862 <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: 3 SSN/Fed Tax ID <br /> Owner ID OW0007124 Case Number: H01367 New Owner ID : <br /> Owner Name THE GEWEKE COMPANY <br /> Owner DBA <br /> Owner Address 871 E ONSTOTT RD <br /> YUBA CITY, CA 95991-3666 <br /> Home Phone Not Specified <br /> Work/BusinessPhone 530-821-4747 <br /> Mailing Address 871 E ONSTOTT RD <br /> YUBA CITY, CA 95991 <br /> Care of GEWEKE, LARRY <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0009862 10182967 <br /> Facility Name GEWEKE AUTO& RV COLLISION CENTER <br /> Location 102 HANSEN DR <br /> LODI, CA 95240 <br /> Phone 209-368-0561 x <br /> Mailing Address PO BOX 929001 IQ2 AW46W by <br /> YUBA CITY, CA 95992 Lodi, I Gig 452AC, <br /> Care of James Foltz <br /> Location Code 02- LODI Alt Phone <br /> Bos District 004-VOGEL, KEN Fax <br /> APN 04323032 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 AR0016862/� New Account ID: <br /> Mail Invoices to Fa Mail Invoices to: Owner / Facility / Account <br /> Account Name 0EWEKE AUTO & RV COLLISION CENTER (Circle One) <br /> Account Balance as of 12/1/2014: $0.00 <br /> (Circle One) <br /> Program/Element and DescriptionRecord ID Employee ID and Name Status Transfer to Active/Inacrve <br /> New Owner? Delete <br /> 1921 -HMSP-Reqular-Primary Location PRO619923 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO514067 EE0001422-ARIS VELOSO Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO512150 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO509862 EE0000o00-HAZ MAT SJC CES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO523742 EE0002622-BENJAMIN ESCOTTO Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533265 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT' I,the undersigned owner,operator or agent a same,acknowledge that all site,andw project spec,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 andor Standards and State andw <br /> Federal Laws. <br /> APPLICANTS 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¢y <br /> REHS: C Date Account out: > Date / / / 7S <br /> COMMENTS: <br /> �o1�N C +�t�\�r� adcfsess w� }4Ar t��2 Law k C* 067AO rL &tws <br />