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Datemn ' 10/8/2015 11:57:OOAI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT ReporUlW21 <br /> Run by Pagel <br /> Facility Information as of 10/8/2015 <br /> Record Selection Criteria. Facility lD FA0018522 <br /> Make changes/corrections in RED ink. Q, �`(S <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 CARMEN, CHARLES C <br /> Owner DBA kX4 / <br /> Owner Address 3524-BRABSOI-CT <br /> Home Phone 700 <br /> Work/Business Phone Not Specified -7,04z/' <br /> •- 9 2Z- 111-,`� `-F <br /> Mailing Address 3524=@ftAf1SCftCT I c)L7J /,4 CA//Iso, r, ... <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0018522 <br /> Facility Name REP/CO AUTO REPAIR <br /> Location 1900 N WILSON WAY <br /> STOCKTON, CA 95205 <br /> Phone 2$9-46537-04 — 2 C-� / O <br /> Mailing Address 1900 N WILSON WAY <br /> STOCKTON, CA 95205 <br /> Care of A 144, S ', <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOIS District 002 - MILLER, KATHERINE Fax 262'1- 62-- 5<D <br /> APN 11714020 EMail: 61114., a <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION /� <br /> Contact Name y�/lam, sG, ,C„— <br /> Title <br /> Day Phone aqq-465-5T%-- ck - Z. —7 6 <br /> Night Phone n" /_ <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> V9 <br /> Account ID AR0032759 4AAp �v New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name REP/CO AUTO RE AIRVV((�`1.(�' (Circle One) <br /> Account Balance as of 10/8/2015: $450.00 <br /> (Circle One) <br /> Transfer to Activelt-actve <br /> Program/Element and Description Record ID Employee ID and Name /ly 9� Status tNeeww Ovine? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0527358 cs` (/ Inactive r\1'J N I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532363 Inactive 'v N I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specHio,PH&EHD hourly charges associateVcl witch th thi���`s 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 ander <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 TypeCheck Number Received l)y <br /> EHD Staff: Date Z 2 / _ Account out: Date <br /> COMMENTS'. ;'.7Q 3 iTs <br /> Invoice#: <br />