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Date run 7/11/2018 2:04:42PIV SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/11/2018 <br /> Record Selection Criteria: Facility ID FA0024639 <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 SSN/Fed Tax ID <br /> Owner ID OW0023244 New Owner ID <br /> Owner Name CAMACHO, VALENTIN <br /> Owner DBA MAIN STREET SMOG <br /> OwnerAddress 2735 PEACOCK GAP CT <br /> STOCKTON, CA 95206 <br /> Home Phone 209-992-7685 <br /> Work/Business Phone Not Specified <br /> Mailing Address 2735 PEACOCK GAP CT <br /> STOCKTON, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0024639 <br /> Facility Name MAIN STREET SMOG <br /> Location 4403 E MAIN ST <br /> STOCKTON, CA 95215 <br /> Phone 209-932-0675 <br /> Mailing Address 2735 PEACOCK GAP CT <br /> STOCKTON, CA 95206 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name VALENTIN CAMACHO <br /> Title <br /> Day Phone 209-932-0675 <br /> Night Phone 209-992-7685 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0046053 New Account ID: <br /> Mail Invoices to Account ��' 1 Mail Invoices to: Owner / Facility / Account <br /> Account Name MAIN STREET OG O JJ (Circle One) <br /> Account Balance as of 7/11/2018: $172.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0543409 EE0008709-JAMIE LIMA Active Y N A 01 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 andtor <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 Tye Check Number Received by <br /> EHD Staff: reFA—h � , Date / / Account out: JZ Date <br /> (�COMMENTS: �/� *JP . <br /> UzI ko� wymj V�1 '� I `�C Invoice#: <br />