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Date run 3/27/2009 1:50:17PI', SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 95021 <br /> Pagel <br /> Ranby Facility Information as of 3/27/2009 <br /> Record Selection Cnte la: Facility ID FA0012110 <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 OW 0009389 New Owner ID <br /> Owner Name MUBARIK, MAHBOOB A <br /> Owner DBA SUPER TIRES&WHEELS <br /> Owner Address 2137 E FREMONT ST <br /> STOCKTON, CA 95205 <br /> Home Phone 209-943-2210 <br /> Work/Business Phone 209-403-5336 <br /> Mailing Address 2137 E FREMONT ST <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012110 <br /> Facility Name SUPER TIRES &WHEELS <br /> Location 3030 WATERLOO RD <br /> STOCKTON, CA 95205 <br /> Phone 209-464-4834 <br /> Mailing Address 3030 WATERLOO RD <br /> STOCKTON, CA 95205 <br /> Care of MUBARIK, MAHBOOB A <br /> Location Code 99 - UNINCORPORATED ,8 Alt Phone <br /> BOS District 001 -GUTIERREZ, STEVE Fax <br /> APN 14313025 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name MUBARIK, MAHBOOB A <br /> Title <br /> Day Phone 209-464-4834 <br /> Night Phone 209-403-5336 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0019388 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name SUPER TIRES &WHEELS (Circle One) <br /> Account Balance as of 3/27/2009: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inadve <br /> Program/Element and Description Record ID Employee ID and Name Status New Omar? Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO515376 EE0009488-JEFFREY WONG Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARIPR0515377 EE0007289-ALISON YOUNGBLOOD Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0522555 EE0003973-ROBERT MCCLELLON Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHS/EHD hourly charges associated with this <br /> facility or ad"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 /> Stale and/or Formal 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 Tty�e Check Number Recelved y <br /> REHS: Date Account Account out: Date 'J /.3D /D <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />