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Date run 4/2/2009 10:29:07AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 46021 <br /> Run by <br /> Facility Information as of 4/2/2009 Pagel <br /> Record Selection Criteria: Facility ID FA0010485 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008485 Case Number: H08203 New Owner ID : <br /> Owner Name HAROLD ALLEN <br /> Owner DBA REPORT RADIATOR <br /> Owner Address 2817 CHERRYLAND AVE <br /> STOCKTON, CA 95215 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-466-6555 <br /> Mailing Address PO BOX 5475 <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010485 <br /> Facility Name REPORT RADIATOR <br /> Location 2817 CHERRYLAND AVE 13 <br /> STOCKTON, CA 95215 <br /> Phone 209-931-0333 <br /> Mailing Address 2817 CHERRYLAND AVE#13 <br /> STOCKTON, CA 95215 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOIS District 002- RUHSTALLER, LARRY Fax <br /> APN 037-100-65 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 AR0017485 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name HAROLD ALLEN (Circle One) <br /> Account Balance as of 4/2/2009: $0.00 <br /> (Circle One) <br /> Transfer to Activeflnacive <br /> Progmm/Elemenl and Description Record ID Employee ID and Name Status New OvmeR Delete <br /> 2220-SM HW GEN<5 TONSNR PRO514349 EE0004636-GARRETT BACKUS Active Y N A D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512773 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0520379 EEOo0000O-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0510485 EEOOOo0OO-HAZ MAT SJC OES Inactive Y N A I D <br /> 3122-STORMWATER INSPECTION-AUTO SHOP PRO522964 EE0004636-GARRETT BACKUS Active Y N AI D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project spec,PHS/EHD hourly charges assoaate with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be perfooned in accordance with all applicable Ordinace Codes and/or Stands s and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date /�/ �''•���"''Nrrpn•• <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Typed Check Number Receiver) <br /> REHS: ewr Date 1. / Z / Account out: (/ Date <br /> COMMENTS: -�X /, �+ �'i <br /> ,,, ZZ2-o 4A� 1If47 i5 c1.'7�. r✓�` <br /> \\eh�nv\envision\reports\5021.rpt X11 I'S l c'n 4- <br /> -5 <br /> - <br /> V /1 �( //69�r <br />