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Date run 8/1/2013 3:38:52PM SAN JOIN COUNTY ENVIRONMENTAL HEA*DEPARTMENT Report#6021 <br /> Run by Pagel <br /> Facility Information as of 8/1/2013 <br /> Record Selection Criteria: Facility ID FA0010714 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN!Fed Tax ID <br /> Owner ID OW0008714 Case Number: H08558 New Owner ID <br /> Owner Name BLAIN, CARL A <br /> Owner DBA <br /> Owner Address 10595 ESCONDIDO PL <br /> STOCKTON, CA 95212 <br /> Home Phone 209-469-2940 <br /> Work/Business Phone Not Specified <br /> Mailing Address 10595 ESCONDIDO PL <br /> STOCKTON, CA 95212 <br /> Care of BLAIN, CARL <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0010714 10,183,771 <br /> Facility Name AXLE PLUS <br /> Location 1450 E SCOTTS AVE <br /> STOCKTON, CA 952056250 <br /> Phone 209-469-2940 x0 <br /> Mailing Address 10595 ESCONDIDO PL <br /> STOCKTON, CA 95212 <br /> Care of BLAIN, CARL <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 15131044 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 AR0017714 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name AXL (} (Circle one) <br /> Account Balance as of 811120Qff) <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Prograrn/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 HMBP-Regular-Primary Location PRO520933 EE0006044-LOWELL ALLEN iv—43 Y N A 1 D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513002 EE0000000-HAZ MAT SJC OES Inac rve Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO510714 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO531864 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: i,the undersigned owner,operator or agent cf some,acknowledge that all site,andfor project specific,PHSIEHO 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 and+or Stardards and State andror <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / 1 <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Receiv d <br /> REHS: _ _ Date 0"1 l Account out: Date$1 1 1-3 <br /> COMMENTS: ` <br />