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Dale am 3/7/2018 8:18:15AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3!7/2018 <br /> Record Selection Criteria: Facility ID FA0018522 <br /> Make changes/corrections in RED ink. ZI if <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0015215 New Owner ID <br /> Owner Name Allen Rider <br /> Owner DBA CHEROKEE MUFFLER& RADIATOR <br /> OwnerAddress 1900 N WILSON WAY <br /> STOCKTON, CA 95205 <br /> Home Phone 209-922-4674 <br /> Work/Business Phone 209-479-5751 <br /> Mailing Address 2822 Marietta Ct. <br /> Stockton, CA 95207 <br /> Care of RIDER,ALLEN <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0018522 10657342 <br /> Facility Name Cherokee Muffler& Radiator <br /> Location 1900 N Wilson Way <br /> Stockton, CA 95205 <br /> Phone 209-462-2610 x <br /> Mailing Address 1900 N. Wilson Way <br /> Stockton, CA 95205 A n h o <br /> Cam of Cherokee Muffler& Radiator <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOB District 002 -MILLER, KATHERINE Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name RIDER,ALLEN <br /> Title <br /> Day Phone 209-462-2610 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0032759 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Allen Rider (circle One) <br /> Account Balance as of 3/7/2018: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inacfve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO540490 EE0009817-ROBERT LOPEZ Active Y N A @ D <br /> 2220-SM HW GEN<5 TONS/YR PR0527358 EE9999996-THREE VACANT3 Active Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO632363 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party id.mmed as the OWNER on this form. I also certify that all operations will he performed in accordance with all applicable Ordinance Codes anNor Standards and State ai <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 Type Check Number Received by <br /> EHD Staff: "1.� Date /_ / Account out: 1/f_ Date / / ) <br /> COMMENTS: <br /> Invoice#: <br />