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Date run 10/18/2017 4:53:36P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/18/2017 <br /> Record Selection Criteria: Facility ID FA0009146 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : <br /> Owner ID OW0007146 Case Number: H01546 New Owner ID <br /> Owner Name Nathaniel Lyons <br /> Owner DBA BUGS COLLISION <br /> Owner Address 1251 E BIANCHI RD <br /> STOCKTON, CA 95210 <br /> Home Phone 209-471-8149 <br /> Work/Business Phone 209-474-3372 <br /> Mailing Address 1251 E BIANCHI RD n D�'. <br /> STOCKTON, CA 95210-3504 bV S2D -D7�[l <br /> Care of LYONS, NATHANIEL <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0009146 10182457 <br /> Facility Name BUGS COLLISION & RESTORATION <br /> Location 1251 E BIANCHI RD <br /> STOCKTON, CA 95210-3520 <br /> Phone 209-474-3372 x <br /> Mailing Address 1251 E BIANCHI RD Pok 57` D <br /> STOCKTON, CA 95210-3504 S — 9�-0710 <br /> Care of Lyons, Nathaniel <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 10416021 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016146 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name BUGS COLLISION & RESTORATION (Circle One) <br /> Account Balance as of 10/18/2017: $298.00 <br /> (Circle One) <br /> Transfer to Active/InacNe <br /> ProgramiElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0519419 EE0008709-JAMIE LIMA Inactive Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0513671 EE0001459-VICKI MCCARTNEY Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO511434 EE00000G0-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509146 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531392 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,he undersigned owner,operator or agent of same,acknowledge that all site,anNor project specific,PHSIEHD hourly charges associated with this facility <br /> 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 Ordinance Codes anrYor Standards and State andror <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: I� IBVOICC iIF: <br />