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Date mn 9/23/2014 8:21:29AR SAN JO�aaaJIN COUNTY ENVIRONMENTAL HEAL `DEPARTMENT Report$5021 <br /> RuA by . Pagel <br /> Facility Information as of 9/23/201 <br /> Record Selection Criteria: Facility ID FA0017757 <br /> Make changes/corrections In RED ink. <br /> INFORMATION CHANGE(date) Nc,.-�S— \ <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSKI Fed Tax ID <br /> Owner ID OW0014584 New Owner ID <br /> Owner Name RIOS, RICHARD <br /> Owner DBA <br /> Owner Address PO BOX 492 ST <br /> STOCKTON, CA 95201 <br /> Home Phone 209-462-3101 <br /> Work/Business Phone 209463-0957 <br /> Mailing Address PO BOX 492 <br /> STOCKTON, CA 95201 <br /> Care of RIOS, RICHARD <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0017757 10186679 <br /> Facility Name RIOS BODY SHOP <br /> Location 1905 E FREMONT ST <br /> STOCKTON, CA 95205 <br /> Phone 209-463-0957 <br /> Mailing Address PO BOX 492 <br /> STOCKTON, CA 95201 <br /> Care of RIOS, RICHARD <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOIS District 001 -VILLAPUDUA Fax <br /> APN 14109025 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030977 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name RIOS, RICHARD (CirdeOne) <br /> Account Balance as of 9/23/2014: $0.00 <br /> (Cinde One) <br /> Transfer to ActiveflnacNe <br /> Progrsm/Element and Description Record ID Employee ID and Name Status New OwneO (Delete <br /> 1921 -HMBP-Regular-Primary Location PR0526236 EE0000006-HAZA SAEED Active Y N A I/ D <br /> 2220-SM HW GEN<5 TONSNR PR0539102 EE0009488-JEFFREY WONG Active Y N A 'I' D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533620 Inactivc Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator w agent or same,acknowledge that all site,and'or project specific.PHSIEHD hourly charges associated wdh this tadlity <br /> wadivity will be billed!to"party idenhtied as the OWNER on this form. I also certify that all operations will be performed m accordance with all applicable Ordinance Codes andor Standards and Slate armor <br /> Federal Laws <br /> APPLICANTS SIGNATURE: C 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 Rece" y <br /> REHS: Date_I r� / Account out: Dat-�anp 0 / /„4 <br /> COMMENTS: <br /> yr QCs \3f 1� <br />