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Date run 9/10/2013 9:47:04AR SAN JOA IN COUNTY ENVIRONMENTAL HEAL- 1EPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 9/10/2013` Pagel <br /> Record Selection Criteria: Facility ID FA0019963 <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 OW0016386 New Owner ID <br /> Owner Name ULLOAS TOW&AUTO REPAIR <br /> Owner DBA ULLOAS TOW &AUTO REPAIR <br /> Owner Address 620 S WILSON WAY <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-943-0588 <br /> Mailing Address 620 S WILSON WAY STE C <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0019963 10,187,473 <br /> Facility Name ULLOAS TOW &AUTO REPAIR <br /> Location 620 S WILSON WAY STE <br /> STOCKTON, CA 95205 <br /> Phone 209-943-0588 x0 <br /> Mailing Address 620 S WILSON WAY STE C <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 15506046 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 AR0035542 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name ULLOAS TOW&AUTO REPAIR (CIrGeOne) <br /> Account Balance as of 9/10/2013: $463.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Progra"Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0530807 EE0006044-LOWELL ALLEN Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532932 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,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 andor <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 /> REHS: Date / / Account out: Date / / <br /> COMMENTS: <br />