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Date <br /> Rue am 11/14/2014 3:34:24F SAN JGVUIN COUNTY ENVIRONMENTAL HEAD DEPARTMENT <br /> Report#5021 <br /> Facility Information as of 11/14/2014 Paga1 <br /> Record Selection Criteria: Facility iD FA0010559 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0008559 Case Number: H08331 Ne Owner ID <br /> Owner Name NGUYEN, THAI <br /> Owner DBA C & C AUTO REPAIR 1 �iS <br /> Owner Address 8700 N THORNTON RD <br /> STOCKTON, CA 95209 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-952-8942 <br /> Mailing Address 8700 N THORNTON RD <br /> STOCKTON, CA 95209 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility lD/CERS ID FA0010559 10183647 <br /> Facility Name C & C AUTO REPAIR <br /> Location 8700 N THORNTON RD <br /> STOCKTON, CA 952091815 <br /> Phone 209-952-8942 <br /> Mailing Address 8700 N THORNTON RD <br /> STOCKTON, CA 95209 <br /> Care of <br /> Location Code 02-LODI Aft Phone <br /> BOS District 003- BESTOLARIDES Fax <br /> APN 07242015 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION ` <br /> Contact NameA. <br /> Title IYI�o�— <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017559 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name NGUYEN, THAI (cirdeOne) <br /> Account Balance as of 11/14/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inadve <br /> ProgranVElement and Description Record to Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO520423 EE0000006-HAZA SAEED Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0517948 EE0000005-FATINAH ZAREEF Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO512847 EE0000o00-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO510559 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO529171 EE0002622-BENJAMIN ESCOTTO Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534240 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge Nat all site,and'or project speck,PHS1EHD hourly charges associated win this facility <br /> oradivity will be billed to"party identifies as the OWNER on this Ron I also cia iy that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ands <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: � i/L[2/ Date /2/ 45 <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date <br /> Water System to be TRAN$FERED: Amount Paid Date <br /> Payment Type ` Check Number Re ved by <br /> REHS: I��L� Date_/ / Account out: Date <br /> COMMENTS: % <br /> C_\)O ge, ow'nkbheg�b <br />