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Daterun 10/30/2015 11:52:54) SAN J IN COUNTY ENVIRONMENTAL HEAW DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/30/2015 <br /> Record Selection Criteria: Facility ID FA0018545 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) C° <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : <br /> Owner ID OW0015233 New Owner ID <br /> Owner Name PHAM, TUAN/RUIZ, JIM <br /> Owner DBA <br /> Owner Address 10423 HENSHAW DR <br /> STOCKTON, CA 95219 <br /> Home Phone 209-607-6795 <br /> Work/Business Phone 209-951-3133 <br /> Mailing Address 10423 HENSHAW DR <br /> STOCKTON, CA 95219 <br /> Care of PHAM, TUAN/RUIZ, JIM <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0018545 10186891 <br /> Facility Name COST LESS AUTO GLASS/AUTO REPAIR <br /> Location 7711 THORNTON RD <br /> STOCKTON, CA 95207 <br /> Phone 209-951-3133 <br /> Mailing Address 10423 HENSHAW DR <br /> STOCKTON, CA 95219 <br /> Care of PHAM, TUAN/RUIZ, JIM <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 07749018 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name TUAN PHAM <br /> Title <br /> Day Phone 209-951-3133 <br /> Night Phone 209-607-6795 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0032821 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name COST LESS AUTO GLASS/AUTO REPAIR (Circle One) <br /> Account Balance as of 10/30/2015: $0.00 <br /> (Circle One) <br /> Transferto Active/Inactve <br /> regramlEJemenl�Qescnptioa-- - - -_—� Record 10 Employee ID and Name Status New Ownel'! '�`De��lete <br /> Gf�N<5 TONSNR PR0527390 E0000005-FATINAH ZAREEF Active Y N A l D <br /> S Nt, �y 053Tg Inactive Y N A 'P D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project speck,PHWHD 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 /> APPLICANTS SIGNATURE: Date /_/ <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number 91.' Received by <br /> EHD Staff: 4Jy;Qh'1 /QA Date /6/�_ Acwunt out: Date_/ /_ <br /> COMMENTS: Invoice#: <br /> � QCii,vk� O��r JrtM ��11 L 5 k�\�c' ��ll -�e4 <br /> lvr.jper) ecc u hcL2cs� ��u5 (tea, W, . Q« WRs no <br /> 1�Ct2crb-oma \.O c,.5� cin S�� C�.S�� �Sl^c.12 �^SpPc�rJ� . <br />