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Data run 1/8/2013 1:56:44PM SAN JO�UIN COUNTY ENVIRONMENTAL HEA? �1 DEPARTMENT Report 05021 <br />Rmfby \/ Pagel <br />Facility Information as of 1/8/2013 <br />Record Selection Catena: Facility ID FA0017767 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0014584 <br />Owner Name <br />RICHARD RIOS <br />Owner DBA <br />RIOS BODY SHOP <br />Owner Address <br />1905 E FREMONT ST <br />Phone <br />STOCKTON, CA 95205 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-462-3101 <br />Mailing Address <br />1905 E FREMONT ST <br />Location Code <br />STOCKTON, CA 95205 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0017757 <br />Facility Name <br />RIOS BODY SHOP <br />Location <br />1905 E FREMONT ST <br />STOCKTON, CA 95205 <br />Phone <br />209-463-0957 x0 <br />Mailing Address <br />1905 E FREMONT ST <br />STOCKTON, CA 95205 <br />Care of <br />Location Code <br />BOS District <br />APN 14109025 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0030977 <br />Mail Invoices to Owner <br />Account Name RICHARD RIOS <br />Account Balance as of 1/8/2013: $0.00 <br />and Description Record ID Employee ID and Name <br />ELECTRONIC REPORTING STATE SURCH,PR0533620 <br />Make changes/corrections InRED Ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / FoA Tnv In �!1 <br />Alt Phone <br />Fax <br />EMail <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Activalnactve <br />Status New Owner? Delete <br />ALLEN Active Y N A jo D <br />Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, Ne 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 Identifietl as the OWNER on this forth I also candy that all operations will be performed in acrx,rdance with all applicable Ordinance Codes andbr Standards and State andor <br />Federal Laws. <br />APPLICANTS SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: • $25.00 = Amount Paid Date // <br />Water System to be TRANSFERED: Amount Paid Dale <br />Payment Type Check Number Receive <br />REHS: Date---/ Account out: Date / T77/ <br />COMMENTS: <br />