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Date run 12/29/2014 8:26:47A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Raped#5021 <br /> Run by Pagel <br /> Facility Information as of 12/29/2014 <br /> Record Selection Cdteda: Facility ID FA0017757 <br /> Make changes/corrections In RED ink. <br /> INFORMATION CHANGE(date) /,:2 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID ;7 'V <br /> Owner ID OW0014584 New Owner ID : <br /> Owner Name RIOS, RICHARD 21G ti tir 10S <br /> Owner DBA <br /> Owner Address PO BOX 492 ST 2G0 rJ <br /> STOCKTON, CA 95201 <br /> Home Phone 209-462-3101 <br /> Work/Business Phone 209-463-0957 <br /> Mailing Address PO BOX 492 <br /> STOCKTON, CA 95201 S G S <br /> Care of RIOS, RICHARD 12 Ipc r I k rfv}2/) <br /> FACILITY FILE INFORMATION <br /> Facility ID/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 /> BOS District 001 -VILLAPUDUA Fax <br /> APN 14109025 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name Richard Rios <br /> Title Owner <br /> Day Phone 209-463-0957 <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 (Circle Owl <br /> Account Balance as of 12/29/2014: $0.00 <br /> (Circle One) <br /> Transfer to Aclive/Inacbe <br /> Progranv Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO526236 EE0000006-HAZA SAEED Inactive 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 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,anclor project specific,PHSIEHD hourly charges associated with Nis facility <br /> or activity will b,billed to Me party identified as the OWNER an this form. Ialsoc oPa ill be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Lewis <br /> APPLICANTS SIGNATURE Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date / / D <br /> Payment Typ Check Number Received by <br /> REHS: Date/Z—/ ZY Account out: _( Date 9 2014 <br /> commrr�re. ERI/IIIpR <br /> PERMITIE RIICESTR <br />