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Datemn 6/28/2016 11:34:06AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Facility Information as of 6/28/2016 Pagel <br /> Record Selection Criteria: Facility ID FA0023535 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) D <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0021824 New Owner ID <br /> Owner Name Lithia of Stockton <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/BusinessPhone 541-776-6401 <br /> Mailing Address 150 N Barlett St <br /> Medford, OR 97501 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0023535 10674121 <br /> Facility Name Kia Of Stockton <br /> Location 6215 Holman Rd <br /> Stockton, CA 95212 <br /> Phone 209-644-6500 x <br /> Mailing Address 6215 Holman Rd <br /> Stockton, CA 95212 <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 AR0043428 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Kia of Stockton (Circle One) <br /> Account Balance as of 6/28/2016: $0.00 <br /> (Circle One) <br /> Transfer to ActivefracNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0541101 EE0008709-JAMIE LIMA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0541100 EE0001459-VICKI MCCARTNEY Active 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 identiFled as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State ands <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 heck Number Received by / <br /> EHD Staff: 1 /� Date / /_� Account out: tf-t> Date I <br /> COMMENTS: IOVOICe#: <br /> C✓ed¢ed �itr �k� dv GAS Gun+ <br /> aH afof�7/It•• ' ill L}yP�rvllco..iS <br />