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DnTemn '9/29/2016 10:43:OOAI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT P." #gaol <br /> Run by Pagel <br /> Facility Information as of 9/29/2016 <br /> Record Selection Catena: Facility ID FA0022074 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) C y <br /> OWNERSHIP CHANGE(date) 0�1 CO <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN <br /> ed Tax ID : <br /> Owner IB--e %LgG46j-7T- er ID : QUza� <br /> Owner Name MOCTEZUMAS, ANTONIO TACK C,A-() <br /> Owner DBA MOCTEZUMAS TIRES &WHEELS <br /> Owner Address 3230 E MAIN ST 'A s) ? r P 114 2!PS% <br /> STOCKTON, CA 95205 <br /> Home Phone 209-938-0907 O zzt <br /> - <br /> Work/Business Phone Not Specified <br /> Mailing Address 3230 E MAIN ST J� 2�JC) L Mctip / <br /> STOCKTON, CA 95205 Q/12 d k1i C+ CIS _L 0 S` <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022074 <br /> Facility Name MOCTEZUMAS TIRES &WHEELS 4 Q0Q11^ <br /> Location 3230 E MAIN ST _ <br /> STOCKTON, CA 95205 <br /> Phone 209-649-4975 <br /> Mailing Address 3230 E MAIN ST <br /> STOCKTON, CA 95205 <br /> Care of MOCTEZUMAS, ANTONIO <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN PAYMENT Ell <br /> EMERGENCY NOTIFICATION CONTACT INFORMA*SCEIVED <br /> Contact Name SEP-2 9 2A --r 4/ CIL <br /> Title <br /> Day Phone SAN JOAOUIN COUNTY _ �5� <br /> Night Phone ENVIROMENTAL r�]] 2 � � <br /> HEALTH DEPARTMENT '7—L- -s' <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0040257 New/ Dun <br /> Mail Invoices to FaClllty Mail Invoices to: Own / Facility / Account <br /> Account Name MOCTEZUMAS TIRES &WHEELS (Circe One) <br /> Account Balance as of 9/29/2016: $0.00 <br /> (Circle One) <br /> Transfer to Actinsfinadve <br /> ProgremEElemenl and Description Record ID Employee ID and Name Status New Owner4elate <br /> 4740-WASTE TIRE SITE-EXEMPT PRO538200 EE0002620-ALFONSO ARAMBULA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project spec,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the party,identified as the OWNER on this form. Ialso cil that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ender <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSF —*$25.010= Amount Paid Date / <br /> Water System to be TRANS ERED: Amount Pa ;.41 oDate <br /> Payment Type Com, ck_Number 44qq Received b <br /> EHD Staff: �^ Date C /=y/ Account out: <br /> COMMENTS: <br /> � Invoice#: <br />