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I <br /> Date run 2120!2013 11:02:53AI SAN JOIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by A i Paget <br /> Facility Information as of 21201201' <br /> Record Selection Criteria: Facility ID FA0010714 ! <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSNI 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 10,595 ESCONDIDO PL <br /> STOCKTON, CA 95212 <br /> Home Phone 209-469-2940 <br /> Work[Business Phone Not Specified <br /> Mailing Address 1450 E SCOTTS AVE 1 s— � j <br /> STOCKTON, CA 952056250 <br /> Care of BLAIN, CARL <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010714 <br /> Facility Name AXLE PLUS <br /> Location 1450 E SCOTTS AVE <br /> STOCKTON, CA 952056250 <br /> Phone 209469-2940 x0 <br /> Mailing Address 1450 E SCOTTS AVE b�`]�J SCD a <br /> STOCKTON, CA 952056250Z- <br /> rare of <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 Owner Mail Invoices to: Owner 1 Facility I Account <br /> Account Name BLAIN, CARL A (circle ones <br /> Account Balance as of 212012013: $350.00 <br /> (Circle One) <br /> Transfer to ActiveJlnactve <br /> Pro ramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 MBP-Regular-Primary Location PRO520933 EE0006044-LOWELL ALLEN Active Y N A I D <br /> AZ MAT BUSINESS PLAN AUTHORIZATIOPPR0513002 EE0000000-HAZ MAT SJC IDES Inactive Y N A I ❑ <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0510714 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PRO531864 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that afl site,andror project specific,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 oerlify that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State and'or <br /> Federal Laws. 4 <br /> APPLICANT'S SIGNATURE: Sem A-WJ - -- Date / ! <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date ! / <br /> Water System to be TRANSFERED: Amount Paid Date ! 1 <br /> Payment Type Check Number Receiv b <br /> RENS: Date 1 ! Account out: Date2- 1 <br /> COMMENTS: <br /> ��`�f/�--fes— /` '^"' i l "` •/�-;-,' <br />