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Date ran 12/29/2014 8:26:47A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Reporn tt5021 <br /> Run by Pagel <br /> Facility Information as of 12/29/2014 <br /> Record Selection Criteria: Facility ID FA0017757 <br /> Make changes/corrections In RED ink. <br /> INFORMATION CHANGE(date) ,,;2 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN/Fed Tax ID : �� <br /> Owner ID OW0014584 New Owner lD <br /> Owner Name RIOS, RICHARD L�(GN/�iLD DS <br /> Owner DBA <br /> Owner Address PO BOX 492 ST <br /> STOCKTON, CA 95201 Y✓ 6A 5 S <br /> Home Phone 209-462-3101 —914914— <br /> Work/Business <br /> S —Work/Business Phone 209-463-0957 6 — 09S <br /> Mailing Address PO BOX 492 O E' r n 't <br /> STOCKTON, CA 95201 S tlK S <br /> Care of RIOS, RICHARD _J21 oS r I -trr rfi.tQ l7 <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017757 10186679 <br /> Facility Name RIOS BODY SHOP <br /> Location 1905 E FREMONT ST <br /> STOCKTON, CA 95205 <br /> Phone 209463-0957 <br /> Mailing Address PO BOX 492 <br /> STOCKTON, CA 95201 <br /> Care of RIOS, RICHARD <br /> Location Code 01 -STOCKTON Alt Phone <br /> Bos District 001 -VILLAPUDUA Fax <br /> APN 14109025 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name Richard Rios <br /> Title Owner <br /> Day Phone 209463-0957 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030977 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name RIOS, RICHARD (CirdeOne) <br /> Account Balance as of 12/29/2014: $0.00 <br /> (Circe One) <br /> Transfer to Active4nactve <br /> PmgraM lemanl and Description Record ID Employee ID and Name Status New Owner' Delete <br /> 1921 -HMBP-Regular-Primary Location PRO526236 EE0000006-HAZA SAEED Inactive Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PR0539102 EE0009488-JEFFREY WONG Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533620 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror 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 formalso ope '11 be performed in accordance with all applicable Ordinance Codes andror Standards and State ander <br /> Federal Laws. J <br /> APPLICANTS SIGNATURE _ Date / o? <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date_/ / <br /> Water System to be TRANSFERED: Amount Paid Date_/_/ D <br /> Payment p Check Number Received by <br /> REHS: Date/7— / I-Y Account out �_ Dated_ 92014 <br /> COMME ENVIII0N <br /> MENt <br /> PERMIT S RV'IfEALT11 <br /> ES <br />