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Datenm 9/29/2017 4:10:41 PA SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Reponaeozl <br /> Run by Pagel <br /> Facility Information as of 9/29/2017 <br /> Record Selection Criteria: Facility ID FA0022837 <br /> Make changes/corrections in RED ink. p42-_c7117 <br /> INFORMATION CHANGE(date) 6 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0020755 New Owner ID <br /> Owner Name MASHIN MOHAMMAD <br /> Owner DBA <br /> Owner Address 10313 ALMANOR CIR <br /> STOCKTON, CA 95219 <br /> Home Phone 209-462-7000 <br /> Work/Business Phone 209-462-7000 <br /> Mailing Address 10313 ALMANOR CIR <br /> STOCKTON, CA 95219 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022837 10646164 <br /> Facility Name CENTRAL VALLEY AUTO TECH O <br /> Location 121 S Wilson Way <br /> Stockton, CA 95205 <br /> Phone 209-462-7000 x <br /> Mailing Address 121 S WILSON WAY <br /> STOCKTON, CA 95205 <br /> Care of MASHIN MOHAMMAD <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 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 AR0041887 New Account ID: <br /> Mail Invoices to AccountI Invoices to: Owner / Facility / Account <br /> Account Name MASHIN MOHAMMAD 3 6'v—e,6 (Circle One) <br /> Account Balance as of6,29/2017: $1,249.00 <br /> w-2— (Circe One) <br /> Transfer to Active/Inadve <br /> ;20 <br /> nt an escription Record ID Employee ID and Name Status New Owner? Delete <br /> MBP-Regular-Primary Location PR0542132 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> -SM HW GEN<5 TONS/YR PR0539930 EE9999996-THREE VACANT3 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this forml also certify that all operations will be performed in accordance with all applicable Ordinance Codes anNor Standard.and stateancvor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Typ Check Number Received <br /> EHD Staff: !L~" Date_/ Z a / Account out: Date b / Z 147— <br /> COMMENTS: Invoice#: <br /> e5 2D17 -6 X01,8 inuoil <br />