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Dale ran 1/10/2013 3:58:43PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Ran by Report x5021 <br /> Facility Information as of 1/10/2013 Pagel <br /> Record Selection Cntena. Facility ID FA0003827 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) 1 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner I OW0002835 New Owner lD <br /> Owner Name VIET MYHUNG VAN VO <br /> Owner DBA MONTE DIABLO AUTO REPAIR L31" <br /> Owner Address 1766 MONTE DIABLO AVE <br /> STOCKTON, CA 95203 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-948-2404 <br /> Mailing Address 1766 MONTE DIABLO AVE <br /> STOCKTON, CA 95203 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0003827 <br /> Facility Name MONTE DIABLO AUTO REPAIR <br /> Location 1766 MONTE DIABLO AVE <br /> STOCKTON, CA 95203 <br /> Phone 209-948-2404 x0 <br /> Mailing Address 1766 MONTE DIABLO AVE <br /> STOCKTON, CA 95203 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 13505050 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003415 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name VIET MYHUNG VAN VO (Circle One) <br /> Account Balance as of 1/10/2013: $0.00 <br /> (Circle One) <br /> Transfer to Actwernactve <br /> Pr ""Element and Description Record ID Employee ID and Name status New Owner? Delete <br /> 1920 HMBP-Common Materials PR0520140 EE0009817-ROBERT LOPEZ Active Y N A D <br /> -USED OIL ONLY-<5 TONS/YR PRO514223 EE0009488-JEFFREY WONG Inactive Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOPPRO512480 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0231190 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0510192 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PRO532789 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party damned as the OWNER on this form I also candy that all operations will be performed in accordance with all applicable Ordinance Codes anclor 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 Check Number Received by <br /> REHS: Date f / /' / Aocoun'.out: -L4!:> Dat /L,�L. <br /> COMMEN <br /> oaz az' IVB P� �� yp (�uS1��5S L `to <br />