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Date run 3/19/2009 2:39:34PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Pagel <br /> Run by Facility Information as of 3/19/2009 <br /> Record Selection Criteria: Facility ID FA0006910 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0005674 New Owner ID : DL tr- KC 17(-,9 D3 <br /> Owner Name SANTIN,-AA- .'5' It <br /> rn' `J <br /> Owner DBA 4 <br /> Owner Address eA ✓� L ��lOt <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address pt-$ <br /> L4 (i-7"7 5 i (!::n Lr` <br /> Care of 0 <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0006910 <br /> Facility Name <br /> Location 3190 AUTO CENTER CIR <br /> STOCKTON, CA 95212 eX 3Y `7 o — -XI <br /> Phone <br /> Mailing Address � e �``S <br /> Care of M SANTIN <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 12802024 EMail : <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name M SANTIN <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> New Account ID: <br /> Account ID AR0009753 <br /> Mail Invoices to Account Mail Invoices to: Owner- / Facility <br /> Air •� c3 t� (Circle One) <br /> Account Name 1" <br /> Account Balance as of 3/19/2009: $0.00 (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description <br /> Record ID Employee ID and Name Status New Owner? Delete <br /> 77- <br /> 2950-ENVIRON ASSESS <br /> PR0505634 EE0000942-MARGARET LAGORIO In ive Y N A I 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 <br /> facility 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date 3 / <br /> Water System to be TRAN ERED: '$372.00= Amount Paid $,3t 5'Date / <br /> Payment Type Check Number r3 Received by <br /> u <br /> REHS: Date Account ot: Date <br /> COMMENTS: <br /> • <br /> \\eh-env\envision\reports\5021.rpt <br />