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Date run 3/30/2009 3:53:27PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/30/2009 <br /> Record Selection Criteria: Facility ID FA0015563 <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 OW0012512 New Owner ID <br /> Owner Name BUSTOS, MANUEL <br /> Owner DBA <br /> Owner Address 2505 E HARDING WAY <br /> STOCKTON, CA 952053528 <br /> Home Phone 650-799-9676 <br /> WorkBusiness Phone 209-466-1574 <br /> Mailing Address 2505 E HARDING WAY <br /> STOCKTON, CA 952053528 <br /> Care of BUSTOS, MANUEL <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015563 <br /> Facility Name EVERMAN BRAKES/WHEELS AUTO REPAIF <br /> Location 2505 E HARDING WAY <br /> STOCKTON, CA 952053528 <br /> Phone 209-466-1574 <br /> Mailing Address 2505 E HARDING WAY <br /> STOCKTON, CA 952053528 <br /> Care of BUSTOS, MANUEL <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOB District 001 - GUTIERREZ, STEVE Fax <br /> APN 14128312 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name MANUEL BUSTOS <br /> Title <br /> Day Phone 209-466-1574 <br /> Night Phone 650-799-9676 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026863 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name EVERMAN BRAKES/WHEELS AUTO REPAIR (Circle One) <br /> Account Balance as of 3/30/2009: $0.00 <br /> (Circle One) <br /> Transferto ActweAnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONSNR PR0523133 EE0009488-JEFFREY WONG Active Y N A I D <br /> 3122-STORMWATER INSPECTION-AUTO SHOP PRO523062 EE0004636-GARRETT BACKUS Inactive Y N ® I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO524076 EE5555555-Garrett Alias-Backus Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated 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 performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> state and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date /_3t2_/_i9 <br /> Program Records to be TRANSFERED: `$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: "$372.00= Amount Paid Date / / <br /> Payment Type Check Number Receiv b <br /> REHS: Date 3 I_ __Qq _Account out: Date / /'PJ <br /> COMMENTS: U <br /> \\eh-env\envision\reports\5021.rpt <br />