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Date mn • 3/27/2009 1:50:50PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Pagel <br /> Run by Facility Information as of 3/27/2009 <br /> Record Selection Criteria: Facility ID FA0014702 <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 OW0011713 New Owner ID <br /> Owner Name DIAZ, JORGE JR <br /> Owner DBA <br /> Owner Address 5262 E ARDELL AVE <br /> STOCKTON, CA 95215 <br /> Home Phone 209-603-2161 <br /> Work/Business Phone Not Specified <br /> Mailing Address 5262 E ARD ELL AVE <br /> STOCKTON, CA 95215 <br /> Care of DIAZ,JORGE JR <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014702 <br /> Facility Name COALCOMAN AUTO REPAIR <br /> Location 1042 S SINCLAIR AVE <br /> STOCKTON, CA 95215 <br /> Phone 209-603-2161 <br /> Mailing Address 1042 S SINCLAIR AVE <br /> STOCKTON, CA 95215 <br /> Care of DIAZ, JORGE JR <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOIS District 002 - RUHSTALLER, LARRY Fax <br /> APN 15908114 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name JORGE DIAZ JR <br /> Title <br /> Day Phone 209-603-2161 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0025009 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner I Facility / Account <br /> Account Name COALCOMAN AUTO REPAIR (ClrcleOne) <br /> Account Balance as of 3/27/2009: $677.00 <br /> (Circle One) <br /> Transform Active/Inactve <br /> Program/Element and Description Record ID Employee 10 and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO524677 EE0009488-JEFFREY WONG Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PRO521628 EEOOOo00O-HAZ MAT SJC OES Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO524721 EE5555555-Garrett Alias-Backus Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project spec,PHS/EHO 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 Standams and <br /> State snorer Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <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 Received by <br /> REHS: Date _/ / Account out: �,� Date / 3010 <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021,rpt <br />