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Date run 2/27/2017 12:02:18PI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/27/2017 <br />Record Selection Criteria: Facility ID FA0019282 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0015824 <br />Owner Name <br />CORVIC TRUCK AND TRAILERS REPAIR <br />Owner DBA <br />CORVIC TRUCKS AND TRAILERS REPAIR <br />OwnerAddress <br />2942 S ODELL AVE <br />Phone <br />STOCKTON, CA 95206 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-948-3510 <br />Mailing Address <br />2942 S Odell ave <br />Location Code <br />STOCKTON, CA 95206 <br />Care of <br />001 - VILLAPUDUA, CARLOS <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0019282 10187161 <br />Facility Name <br />CORVIC TRUCKS AND TRAILERS REPAIR <br />Location <br />1181 S WILSON WAY <br />STOCKTON, CA 95205 <br />Phone <br />209-948-3510 x <br />Mailing Address <br />2942 S Odell ave <br />STOCKTON, CA 95206 <br />Care of <br />CORVIC TRUCK AND TRAILERS REPAIR <br />Location Code <br />01-STOCKTON <br />Bos District <br />001 - VILLAPUDUA, CARLOS <br />APN <br />15135030 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0034296 <br />Mail Invoices to Account <br />Account Name BIG GZ PA T O <br />Account Balance as of 2/27/2017: 9.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phon <br />Fax <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Acti actve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Dele <br />1921 - HMBP-Regular-Primary Locati n PR0528719 EE0009817 - ROBERT LOPEZ Active Y N I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGI PRO531618 Inactive Y N A D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD 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 andror Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date <br />Water System a NSFERED: Amount Paid Date <br />Payment Typ Check tuber Received by <br />EHD Staff: Date �/ / Account out: Date <br />COMMENTS: <br />Invoice #: <br />