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Rivera Auto Service Record ID# PR0523300 <br /> 1402 E Miner Ave Stockton, CA 95205 Program: HW <br /> August 21, 2019 <br /> PHOTO 1: DTSC form 1358 was filled out to be faxed or emailed to the DTSC while inspector was on site to reactivate State ID: CAL000289534 <br /> - <br /> 'NEyy. Uryl� rat a,u,ecpou Alan u.p,,, <br /> I� ,. I eR RE4u�.-_ PERMAN � •"r`^^�mu,"°„w�.,.A„ <br /> ly­ <br /> sme°oa rt�w n�a new aermanenrr armE <br /> y <br /> rlYpurG �A 3ArTEr pD NUeryIEER APPUC ar "';'nrl M sry.x, r.+s. <br /> sa6parts sa 8en°raras be A r c°'!_ora ID ATIDN `n^.rw;"`�nra <br /> r (cl and(dl oar rnonrfi rR r!I n I�- Ian numb s a ilaa d 4 -- <br /> S Ir <br /> F°r exisl ng 1p number INF() <br /> I)N INF �br Pay q."&700 i2!gJwasle, e0 f.-GxnLr" Tracy _l <br /> Ll 2 n'6er. C QO AT N Ralcderar @pA lD ru�pe nnza.q awaLealsWaheaa eh$. <br /> am upaahng the E SPIN g — H1.M.p reee <br /> 3. I am inactiva rnailin9 addre <br /> El <br /> NUMa q <br /> I em Ieactrvalin9 this Ip nurn6er�anernr coo,act ih(armntlan only, <br /> 5, I an changing theh I�number Reasah(nleav <br /> TY - nSinga3 name onl eselect Onel. q <br /> Non-5401 Q. SirelFacilRYlgusin Y n°ownership change. • erirprion puesryonrta�r¢ d <br /> 'No Plac ess Name I <br /> 7- Site Location: � (ndorf <br /> Nan-RC <br /> -No pie <br /> e-(al Federal empmvar to N /v f C � � l C <br /> Nan- unther State 20 - <br /> -No -�jhl beard ofEarose I <br /> ((44)is..My, VualRall <br /> required/ym°n Foe A u°um Numbrr <br /> 55� 9 Mallrn9 Address: _ S°narar°rs orgrratennan s eansper oalenn;,r <br /> �ryavt <br /> N _! <br /> c <br /> say Q <br /> 10. Srle Contact PersAn: /.._+ � ode <br /> Nat Name V��° _ <br /> pESFfbI <br /> Conradi person Ad&-441 has!Nam= <br /> � r t C /'/ <br /> 161.1 xy A <br /> West S Contact Pars Sol. - <br /> on Phone Number: � -�i�f LP cone <br /> Arse phone Number raxNumber: <br /> iNtPORTANT NOYN Contac(PersoRBusiness Email Addr A(¢a Code Fax Nnmher <br /> Crystal blue Envlm eSs;. <br /> ragulal+ons appli <br /> agement(aoidi, <br /> that process a gat Business Owner(not property gwnerj: r <br /> integrity and m*l Owner Address' N a 0 , <br /> management-to - - ` N <br /> GENERATORS" Owner Phone Number,re U <br /> are m'a la,90 Pr ) <br /> City State Zip C¢de <br /> If I am a large� Area''de Fax Nsrmber. (,� <br /> hone Numbs Area Cpde <br /> to bs aconomfp Fax-Number <br /> present add NO 12. Standard Industrial Classftatron.(SJC)Code far the.5ite: <br /> generated and (4-Digit Number) <br /> ;nyotherhaza <br /> of the eppliph 13: CerlificaGon:1 certify under penalty flaw that Me information on this document was prepa <br /> rntom,aUon I h belief to be true,accurate and piste. red to the best of my knowledge and <br /> Generat SIGNATURE(ha ritten D <br /> Contact Name(prinq /y/ pha e <br /> Transp r'r <br /> 6 EITSC Form 1358(08/18) - <br /> IJ,(7 Page 3 of 3 <br /> Tricia Dai, EHS Page 1 of 4 <br />