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Date m� . 711 312017 1:47:11 PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Run by <br />Facility Information as of 7/13/2017 <br />Facility ID FA0012818 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0009993 <br />Owner Name <br />SINGH, JARGENDER <br />OwnerAddress <br />404 ENGLEWOOD LN <br />MODESTO, CA 95356 <br />Home Phone <br />209-529-2050 <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />650 E MINER AVE <br />STOCKTON, CA 95202 <br />Care of <br />FACILITY FILE INFORMATION <br />FacilityID / CERS ID <br />FA0012818 <br />Facility Name <br />C <br />Location <br />650 E MINERAVE <br />STOCKTON, CA 95202 <br />Phone <br />Mailing Address 4143 MC HENRYAVENUE <br />MODESTO, CA 953561513 <br />Care of JARGENDERSINGH <br />Location Code 01-STOCKTON <br />BOIS District ll ll <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name JARGENDERSINGH <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0021538 <br />Mail Invoices to Facility <br />Account Name CAPITOLAUTO SALES <br />Account Balance as of 7/13/2017: $0.00 <br />Report*5021 <br />Pagel <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) A0[ (L-1 PI XS <br />SSN / Fed Tax ID <br />New Owner ID <br />4Ci Pd :e L:t <br />S+w-I nn LA (A5ano1 <br />ICA - CA s D - 13,A 5 <br />•b 001 ^ (P a — LIq l,l (o <br />iksk t e -k kD WgC' <br />[p"D o E M. 10 e- <br />S�oLLLiun (_R 0\J 0— <br />Alt Phone <br />Fax <br />EMail : <br />Dr�r <br />1n4—N1.a— NOV4(o <br />a v°I 57' 'a3 015 <br />New Account ID: <br />Mail Invoices to: Owner / acl I / Account <br />(Cirde One) <br />(Circle One) <br />Transfer to Activelnactee <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />2381 - UST FACILITY (BEFORE 1/84) - obsolete PR0516807 EE0000008 - LETITIA BRIGGS Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, ander project specific, PHSIEHO hourly charges associated with this facility <br />or activity will be billed to the parry identified as the OWNER on this forte. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and'or Standards and State andor <br />Federal Laws. <br />APPLICANTS SIGNATURE: <br />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 />EHD Staff: Date �/�3_/� Account out: /,e` Date / IS /1-7 <br />COMMENTS: <br />Invoiceu:.2.9505g <br />