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Date raft^ x/2013 12:29:07F SAN JO fIN COUNTY ENVIRONMENTAL HEA DEPARTMENT <br /> Run by Report#5621 <br /> Facility Information as of 10/18/2013 Pagel <br /> Record Selection Criteria: Facility ID FA0004959 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) r Ob/ <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0014626 New Owner 1D <br /> Owner Name KARIMI, MANSOOR 7 <br /> Owner DBA <br /> Owner Address CT (� Ck vt,c:- <br /> TR 76 'Pr1 ll G�on Q Fes' , (2-A -7 '-7 <br /> — <br /> Home Phone 72g-a85-968.1 Q - <br /> Work/Business Phone 209-463-9500 <br /> Mailing Address 1 T <br /> TR i V_C�_ C_�g C—A-- <br /> care of KARIMI, MANSOOR <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0004959 10,181,699 <br /> Facility Name TRI VALLEY AUTO DISMANTLERS <br /> Location 930 E DR MARTIN LUTHER KING JR BLVD <br /> STOCKTON, CA 95206 <br /> Phone 209_463-9500 <br /> Mailing Address d��d ST^Wff. fr+r+r n ��' "� [Yl��, <br /> rv�-r�v i n i�urs r�v'C-t�7T�I�i o Y D W Y1 L1r' [ 30 C �^ii,'yl Y <br /> T ok n►'t-� �15� �� Jew <br /> Care of KARIMI, MANSOOR <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> Al 16718303 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 AR0005401 New Account Ill <br /> Mail Invoices to Facility Mail Invoices to: Owner I Facility / Account <br /> Account Name TRI VALLEY AUTO DISMANTLERS (Circle one) <br /> Account Balance as of 10/18/2013: $200.00 <br /> (Circle One) <br /> ProgramlElement and Description Record ID Employee ID and NameTransfer to ActiveAnactve <br /> Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0521105 EE0009817-ROBERT LOPEZ Active Y N A I - D <br /> 2217_APPLIANCE RECYGL-ER PR0521509 LE0001421 STACY,RIVERA Inactive Y N A I D <br /> 2220-SM HW GEN 55 TONS/YR —PR-052 <br /> PR0517682 - +EE0001421-rSTACY RIVERA _ ��'Active Y N A I D <br /> 2220-SM HW GEN a5 TONS/YR l - -: —PR0521746- EE0001421 SYACY RIVERA __�Inactil Y N A I D <br /> 2224-HAZ MAT BUSINESS PIAN AUTHORIZATION PRO517681 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1184)-obsolete PRO500994 EE0000008-LETITIA BRIGGS Inactive Y N A [ D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO517683 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0523946 EE0002620-ALFONSO ARAMBULA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534579 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 prcjgct specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form t also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or standards and State ardor <br /> Federal Laws, <br /> PLICANTS GNATURE: <br /> Date /—I— <br /> Program <br /> 1Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date 1 / <br /> Payment Type I Check Number Received by <br /> REHS: Date W 1 �-/ / � Z <br /> —+ -- Account out: �(� pate /0-Y /K / / <br /> COMMENTS: 3 <br /> -, " fro d."�� � ( ()/zz-1 r3 <br />