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Date run 2/9/2016 10:22:45AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 2/9/2016 <br />Record Selection Criteria: Facility ID FA0009012 <br />Make changes/corrections 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 OW0007012 Case Number: <br />H00167 New owner ID : <br />Owner Name 4pa�p <br />A!Si L LhQN <br />Owner DBA PAYLESS AUTO REPAIR INC <br />Owner Address 26 N CHEROKEE LN #B <br />Z p <br />LODI, CA 95240 <br />Home Phone -2g@ <br />Work/Business Phone 209-642-6065 <br />Mailing Address 26 N CHEROKEE LN #B <br />LODI, CA 95240 <br />CareofTELKv <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0009012 10182347 <br />Facility Name PAYLESS AUTO REPAIR INC <br />Location 26 N CHEROKEE LN STE B <br />LODI, CA 95240 <br />Phone 2.9 <br />'V�L %04 ~ 2411%3 <br />Mailing Address 26 N CHEROKEE LN #B <br />LODI, CA 95240 <br />Care of .pPPPPPPEI Q-FRAPd _ <br />_MA `IlLh,,1 <br />Location Code 02 - LODI <br />Alt Phone <br />BOS District 004 - WINN, CHARLES <br />Fax <br />APN 04321027 <br />Entail: <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />451A ILh�h1 <br />Contact Name <br />Title <br />O�-3N f -;R <br />Day Phone <br />7W 12m 933 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0016012 <br />New Account ID: <br />Mail Invoices to Account <br />Mail Invoices to: Owner / Facility / Account <br />Account Name PAYLESS AUTO REPAIR INC <br />(Circle One) <br />Account Balance as of 2/9/2016: $363.00 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID <br />Employee ID and Name Status New Owner? Delete <br />1920 - HMBP-Common Materials PR0519324 <br />EE0008709 - JAMIE DE LA ROSA Active Y N A I D <br />2220 - SM HW GEN <5 TONSNR PR0513581 <br />EE0001422 - ARIS VELOSO Active Y N A I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511300 <br />EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PRO509012 <br />EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO532828 <br />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 facility <br />or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations <br />will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br />Federal Laws, <br />APPLICANT'S SIGNATURE: <br />Date / ! <br />Program Records to be TRANSFERED: $25.00 = <br />Amount Paid Date <br />Water System to be TRANSFERED: <br />Amount Paid Date <br />Payment Type\� Check Number <br />Received by <br />EHD Staff: ti Date. /�/_ > Account out: C45 Date <br />COMMENTS: <br />Invoice #: <br />