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Date ran 4/30/2013 2:34:5113h SAN JUIN COUNTY ENVIRONMENTAL HEAW DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 4/30/2013 <br /> Record Selection Criteria: Facility ID FA0009711 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> WNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION S /Fe I74-V-1 i g <br /> Owner ID OW0007711 Case Number: H05199 NewOwner D-- <br /> OwnerName DEEJILL INC 3RFwf-R EA)QR PRISES TVC, <br /> Owner DBA MIDAS MUFFLER & BRAKE I V7 5F- Pc75 <br /> Owner Address 5897 PACIFIC AVE 71 Ynil L/4 12iF_ 't <br /> STOCKTON, CA 95207 PAwl eC,Q_ C A , 9 _33 7 — <br /> Home Phone Not Specified <br /> Work/Business Phone 209-951-5685 <br /> Mailing Address 5897 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Care of MARCHICK, ALAN � ILL R PfaieA— <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0009711 10,182,835 <br /> Facility Name-MIDAS MUFFLER & BRAKE rq 1111)4S Ay l o 56 eyt cf F k ,81J <br /> Location 5897 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Phone 209-951-5685 _ Dt�_ <br /> Mailing Address 5897 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002-RUHSTALLER, LARRY Fax <br /> APN 10812032 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION n <br /> Contact Name ti L {z f WF/( <br /> Title 1 P <br /> Day Phone D 9 SLTI;- ';o f? <br /> Night Phone Ll t* <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016711 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / acility / Account <br /> Account Name DEEJILL INC �Nvn pQ w <br /> Account Balance as of 4/30/2013: $0.00 LJ 6 L <br /> (Circle One) <br /> Transfer to Activdlnactve <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location P11051.EE0006044-LOWELLALLEN Active if N A 1 D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATI01PRO51199J— EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> —2227-GEN 5<25 TONS PERMIT PR0517870 EE0004636-GARRETT BACKUS Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0509711 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO523248 EE0002620-ALFONSO ARAMBULA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHIPR0534519 Inactive 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 specifc,PHSIEHD 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 will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws. <br /> 0 Date �Ir 3d/ 20 )3 PAYMENT <br /> APPLICANT'S SIGNATURE:�/I/t�- RECENED <br /> Program Records to b `$25.00= Amount Paid ate / � APR 3 2013 <br /> Water System to b TRAN FERED: Amount Pai Date L 17m/ 1 <br /> Payment Type Check Number Received by - QUIN COUNTY <br /> REHS: Date /_/_ Account out: Date_I/_ { HOMENTAL <br /> COMMENTS: V�' / � � . / HEALTH DEPARTMENT <br /> ��.t7 � ' ��ls�l3 - (y�3���3 <br />