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Date run 3/30/2009 3:49:47PK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/30/2009 <br /> Record Selection Cmena: Facility ID FA0012502 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0009705 New Owner ID <br /> Owner Name GARCIA, GUSTAVO <br /> Owner DBA <br /> Owner Address 2420 E WATERLOO RD <br /> STOCKTON, CA 95205 <br /> Home Phone 209-466-4498 <br /> Work/Business Phone Not Specified <br /> Mailing Address 2420 E WATERLOO RD <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012502 <br /> Facility Name WATERLOO SMOG <br /> Location 2420 E WATERLOO RD <br /> STOCKTON, CA 95205 <br /> Phone 209-466-4498 <br /> Mailing Address 2420 E WATERLOO RD <br /> STOCKTON, CA 95205 <br /> Care of GARCIA, GUSTAVO <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 001 -GUTIERREZ, STEVE Fax <br /> APN 14128217 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name GUSTAVO GARCIA <br /> Title <br /> Day Phone 209-466-4498 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0020414 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name WATERLOO SMOG (Circle One) <br /> Account Balance as of 3/30/2009: $0.00 <br /> (Circle One) <br /> Tmnsferto Active/Inaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO516190 EE0009488-JEFFREY WONG Active Y N A 1 D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO518845 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPRO516191 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 3122-STORMWATER INSPECTION-AUTO SHOP PR0523073 EED009488-JEFFREY WONG Inactive Y N 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 forth. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> Stale and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Date ,`J / <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Recei y <br /> REHS: Date ' / 5 a / Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />