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Date run 9/29/2015 4:43:20PR SAN JOIN COUNTY ENVIRONMENTAL HEA*DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/29/2015 <br /> Record Selection Criteria: Facility ID FA0017842 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSNIFed Tax ID : <br /> Owner ID OW0012270 New Owner ID <br /> Owner Name BAYANZAY, KARIMALLAH <br /> Owner DBA <br /> Owner Address 12773 N LOWER SACRAMENTO RD <br /> LODI, CA 952429225 <br /> Home Phone 209-747-5177 <br /> Work/Business Phone Not Specified IV I <br /> Mailing Address 12773 N LOWER SACRAMENTO RD <br /> LODI, CA 952429225 <br /> Care of BAYANZAY, KARIMALLAH <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017842 <br /> Facility Name INTERNATIONAL AUTO DISMANTLER <br /> Location 930 E CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Phone <br /> Mailing Address 3725 MASSIMO CIR <br /> STOCKTON, CA 95212 <br /> Care of BAYANZAY, KARIMALLAH <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 16718303/5 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name BAYANZAY, KARIMULLAH <br /> Title OWNER <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0031203 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name INTERNATIONAL AUTO DISMANTLER (Circle One) <br /> Account Balance as of 9/29/2015: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inai <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0526361 EE0000942-MARGARET LAGOR10 Active 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 facility <br /> or activity will be billed to the party identified as the OWNER on this formlalsocertify that all operations will be performed in accordance with all applicable Ordinance Cortes andor Standards and State endor <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 Type Check Number Received by <br /> EHD Staff: Date I / Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />