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Date run 4/8/2015 11:49:02AM SAN JOAQUIN COUNTY ENVIRONMENTAL HF,ALTH DEPARTMENT <br /> Run by Report;; <br /> Facility Information as of 4/812015 Pagel <br /> [Record Selection Criteria: Facility ID FA0011011 <br /> Make changes/corrections in RED ink. _ <br /> INFORMATION CHANGE(date) r 8 0v ! <br /> OWNERSHIP CHANGE(dale) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 5SN/Fed Tax ID <br /> Owner ID OW0009011 Case Number: H09151 New Owner ID <br /> Owner Name Daljit Singh <br /> Owner DBA DK EXPRESS 5 <br /> Owner Address 2000 W CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Home Phone Not Specified <br /> WorklBusiness Phone 209-954-9354 <br /> Mailing Address 2000 W Charter Way <br /> Stockton, ca 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID!CERS ID FA0011011 10184029 <br /> Facility Name DK Express -,1L <br /> Location 2000 W CHARTER WAY ' <br /> STOCKTON, CA 95206 <br /> Phone 209-954-9354 x <br /> Mailing Address 2000 W Charter Way <br /> Stockton, c 95206 <br /> Care of DK Express <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SINGH, SARB <br /> Title OPS MGR <br /> Day Phone 209-954-9354 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0018011 New Account ID: _ <br /> Mail Invoices to Facility Mail Invoices to: Owner l Facility I Account <br /> Account Name DK Express Qt1V�0 1 I.yt.LJ (Cil One) <br /> Account Balance as of 41812015: $0.00 J <br /> (Circle One) <br /> Transfer to Activelli <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO520606 FF0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO514489 EE0002646-THUY TRAN Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513299 FF0000000-HAZ MAT SJC OES InactivE Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0511011 EE0000000-HAZ MAT SJC OES InactivE Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0524626 EE0009000-HARPRIT MATTU Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534074 InactivE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor 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 form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and+or Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! i <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date ! l <br /> Water System to be TRANSFERED: Amount Paid Date ! l <br /> Payment Type Check Number Received y <br /> REHS: L�� �J o Date L ! 1 "C' Account out: Date <br /> COMMENTS: <br /> q1 �y'1'�n_ s t1�tl'�- Cl-wo � �`C � Cay°��, +lcftc �� �u�'iC y Gem <br />