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Date run 12/15/2014 1:42:58P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Run by Report 45021 <br /> Facility Information as of 12/15/2014 Pagel <br /> Record Selection Criteria: Facility ID FA0015385 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 <br /> SSN/Fed Tax ID <br /> Owner ID OW0012353 New Owner ID <br /> Owner Name SINGH, SURINDER <br /> Owner DBA S & S AUTO SALES REPAIR SHOP <br /> Owner Address 845 N WILSON WAY <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 845 N WILSON WAY <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0015385 10184935 <br /> Facility Name S & S AUTO SALES REPAIR SHOP <br /> Location 819 N WILSON WAY <br /> STOCKTON, CA 95205 <br /> Phone 209462-7327 <br /> Mailing Address 845 N WILSON WAY <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 15107505 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name Jose Gonzalez <br /> Title Business Manager <br /> Day Phone 209462-7327 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026499 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name S &S AUTO SALES REPAIR SHOP (Circle One) <br /> Account Balance as of 12/15/2014: $0.00 <br /> (Circle One) <br /> Transferto Actio nacwe <br /> Program/Element and Description Record ID Employee 10 and Name Status New Owner] Delete <br /> 1920-HMBP-Common Materials PR0523286 EE0000006-HAZA SAEED Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO522581 EE0009488-JEFFREY WONG Active Y N A� D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO531584 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,ander project spec,PHSIEHD hourly charges associated with this facility <br /> or acbvitywill be billed to the parry 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 /> 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: Dater /_Z_!Zt-Account out: Date <br /> COMMENTS: <br />