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Date run 8/14/2014 4:14:17PR SAN K IN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 8/14/2014 <br />Record Selection Criteria: Facility ID FA0022511 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID OW0020033 <br />Owner Name jerold brannon <br />Owner DBA <br />Owner Address <br />Home Phone Not Specified <br />Work/Business Phone 209-466-1881 <br />Mailing Address po box 2496 <br />stockton, ca 95201 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0022511 10446553 <br />Facility Name <br />Valley Auto Sales <br />Location <br />2272 N Wilson Way <br />Stockton, CA 95205 <br />Phone <br />209-546-7827 x <br />Mailing Address <br />2282 n wilson way <br />stockton, ca 95205 <br />Care of <br />greg barrows <br />Location Code <br />BOS District <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <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 Phone <br />Fax <br />EMail : <br />Account ID AR0041191 <br />Mail Invoices to Facility Mail Invoices to: <br />Account Name Valley Auto Sales <br />Account Balance as of 8/14/2014: $0.00 <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />CB1920 - HMBP-Common Materials PR0539376 EE0000006 - HAZA SAEED Active Y N A I D <br />2220 - SM HW GEN <5 TONS/YR PR0539375 EE0009488 - JEFFREY WONG Active Y N A I 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 and/or 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 to be TRANSFERED: Amount Paid Date <br />Payment Type Check Number Rece y <br />REHS: Date �_/�/� Account out: Date / ! <br />COMMENTS: <br />Nkqw "CxJ-% M J- P*A)tNaA(-AS <br />CV %Ac CCS -5 <br />1N -.1, g 3 <br />