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Date run 1/15/2013 11:57:11AI SAN JON COUNTY ENVIRONMENTAL HEALEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1115/201 <br /> Record Selection Criteria: Facility ID FA0018094 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0014840 New Owner 1D <br /> Owner Name DAVILA, CESAR <br /> Owner DBA <br /> Owner Address 1818 TORINO DR <br /> STOCKTON, CA 952052564 <br /> Home Phone 209-817-3711 <br /> Work/Business Phone 209-469-3882 <br /> Mailing Address 1818 TORINO DR <br /> STOCKTON, CA 952052564 <br /> Care of DAVILA, CESAR <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0018094 'T IWS ►VtA51rWt3�5 15 X t.6nlCti <br /> Facility Name MASTER AUTO REPAIR I A ^I'fiT% <br /> Location 3091 N WILSON WAY AzIll X-` <br /> STOCKTON, CA 95205 <br /> Phone 209-817-3711 <br /> Mailing Address 1818 TORINO DR <br /> STOCKTON, CA 952052564 <br /> Care of DAVILA, CESAR <br /> Location Code 99- UNINCORPORATED P Ait Phone <br /> BOS District 002- RUHSTALLER, LARRY Fax <br /> APN 11904225 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name q <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION \� <br /> Account ID AR0031829 �J New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name MASTE AIR (Circle One) <br /> Account Balance as of 1/15/201 3,163.30 <br /> (circle ono) <br /> Transfer to Activellril <br /> M <br /> PrograElemenl and Description Record ID Employee lD and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0530836 -- _ Inactive Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0526723 EE0004636-GARRETT BACKUS ActivlY N A q D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH�PR0533730 �Thactive Y N A Y D <br /> BILLING and COMPLONICE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge Nat all site,andor 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 cenify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State and/or <br /> Federal Laws <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / I <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date / / <br /> COMMENTS: <br />