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Date run 1/6/2013 1:56:44PM SAN JO UIN COUNTY ENVIRONMENTAL HEA/ 1 DEPARTMENT Report#5021 <br /> Ralfby <br /> Facility Information as of 1/8/2013 Pagel <br /> Record Selection Criteria: Facility ID FAD017757 <br /> Make changestcorrections in RED ink. ' <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0014584 New Owner ID : — <br /> Owner Name RICHARD RIOS <br /> Owner DBA RIOS BODY SHOP E <br /> Owner Address 1905 E FREMONT ST <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-462-3101 Ae <br /> Mailing Address 1905 E FREMONT ST <br /> STOCKTON, CA 95205 <br /> Care of j N <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017757 <br /> Facility Name RIOS BODY SHOP <br /> Location 1905 E FREMONT ST <br /> STOCKTON, CA 95205 <br /> Phone 209-463-0957 x0 <br /> Mailing Address 1905 E FREMONT ST <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code Alt Phone <br /> BOB District 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 RICHARD RIOS (Crete One) <br /> Account Balance as of 1/8/2013: $0.00 <br /> (Circle One) <br /> Transferto Acbve/lnactve <br /> Pm raMElement and Description Record ID Employee ID and Name Status New 0..0 Delete <br /> 1921 - MBP-Regular-Primary Location PRO526236 EE0006044-LOWELL ALLEN Active Y N A jo D <br /> 'ElC-ELECTRONIC REPORTING STATE SURCH,PRO533620 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anNor protect specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party Identified m the OWNER on this form I also combly that all operations will be performed in accordance with all applicable Ordinance Codas andior Standards and State aruyor <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 Receive <br /> RENS: Date�/ /1� Account out: <br /> COMMENTS: <br />