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Excelente Auto Body & Frame Record ID# PR0535865 <br /> June 5, 2019 Program: HW <br /> 1538 Nellis St STE C, Stockton, CA 95205 <br /> PHOTO 1: DTSC form 1358 was filled out and emailed to the DTSC while inspector was on site to reactivate State ID: CAL000381406 <br /> — ®S Conrrol <br /> S E 1 xic Subeten�+M ,mynt <br /> pepeMi WW lnlanp n <br /> L ®SrJo1 a7 Y17 r Gleof En°N <br /> LIC <br /> MST-A — <br /> �rC;w•sc .caue^x'ee..�m PERM EN� EI _N ��inx_ aerator ❑Trenj,8ng� <br /> f 00 0 Wrierofbu 4(1 r')`17261.5 <br /> x <br /> imw Mrr�npiedo I omaer ae❑B flase heza doua west¢listed in <br /> I lam aPONme a o Nm'ern SRA ln.e�w�aIEPA ID nlunber. <br /> R°MmWaMa peNar mane Fgrn B7�14 r�� <br /> STATE ID UMBER <br /> OSTING Q- (p <br /> TNS <br /> lamewme to m,nmer C A_¢ nbu�nbm�anon only B. ❑ Other <br /> L,slam aaaaune aw marine admass an <br /> �mea e"'e mN ID numba� A� Verification QuesEonnaire <br /> am realNsa�W IMS ID numMer Reason 1pgeze Xlenonel <br /> 3 1(a and yin911re bwuicsa name onN rw owrership change <br /> sFness Name flncNda OBA)' <br /> sx i man. A/tl r S S.� G <br /> s <br /> t r c4 zPC.". c N <br /> s <br /> �d lal fe0a'alEmplara' (Ibll 9eAfgtelhID._-1 405 (e)elf� on Fereran 5 tansper <br /> e.wnnaAaaresa. IS78" N!/l3 s'>t SLI-,a Z <br /> Q�rG�. Lra 4Stas <br /> Ca. abre Zg Cotle <br /> 're SCoraaC P¢rsan. l�..i\ `�� eZ <br /> Nene Lasl Ndme <br /> Canbci Person Address.—1 F?k A2C(Jr s S/` SV}e e <br /> C� Sb <br /> Doraecr Person PMne Number ZP Coda <br /> Fu NDmber.Legr <br /> Nu9S Z 23 9 <br /> Cade Pnone m1bsr Area Cede Fax <br /> Cantaq Person Business Email Address e <br /> In <br /> Number <br /> tl�Busmess Dlvner mm PlapaigrawnerJ. � <br /> Dwne-Af-, <br /> DanerPMne Number Qom_ C Clty UR YSZO <br /> A- Pn—3N FM Number.(dretate, Z3+p Coe s <br /> Area Code <br /> 12.Stmd&e Im--Clas <br /> aFax Number <br /> n(SIC) Fax <br /> for the Site: 5' <br /> 13.I%N filb be lcereyu (4-Di <br /> fie&'1ro Be rPoe, n�rp°naN a/Hwrhal rhe' -Number) <br /> aoeurefe aMCwwleM rnlomrabon on this tloPumenf web Onep2redb�® <br /> SIGNATNREF'4tt <br /> Name� bear of my knowledge and <br /> DTSD Fm,,,+dsTitle �t..a42! Date �[ <br /> — <br /> phone to Z2-J Y <br /> IL <br /> page 3 Of 3 <br /> Tricia Dai, EHS Page 1 of 5 <br />