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Date run 9/3/2013 12:23:36PM SAN Ji,UIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by #"�' Pagel <br /> Facility Information as of 9I3I2013 <br /> Record Selection Chileans: Facility ID FA0010162 <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 OW0008162 Case Number: H06985 New Owner ID <br /> Owner Name MARTIN, WADE <br /> Owner DBA <br /> Owner Address 3261 CHERRYLANDAVEINIE5 Ll <br /> STOCKTON, CA 95376 <br /> Home Phone 209-931-8137 <br /> Work/Business Phone 209-969-7178 <br /> Mailing Address 2953 CHERRYLAND AVE#B <br /> STOCKTON, CA 952152233 <br /> Care of MARTIN, WADE <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0010162 10,183,281 <br /> Facility Name OFF ROAD ENTERPRISES <br /> Location 2953 CHERRYLAND AVE B <br /> STOCKTON, CA 95215 <br /> Phone 209-931-1170 <br /> Mailing Address 2953 CHERRYLAND AVE#B <br /> STOCKTON, CA 952152233 <br /> Care of MARTIN, WADE <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 08710046 Eli <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017162 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name MARTIN, WADE (circle one) <br /> Account Balance as of 9/3/2013: $3,953.50 <br /> (Circle One) <br /> Transfer to Activellnaclve <br /> Program/Element and Description Record ID Employee 10 and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0520111 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0514207 EE0004636-GARRETT BACKUS Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO512450 EEo000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO510162 EE0000o00-HAZ MAT SJC OES Inactive Y N A I D <br /> 3122-STORMWATER INSPECTION-AUTO SHOP PR0522965 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532890 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator ix agent of same,acknowledge that all site,andor project specific,PHS/EHO hourly charges associated with this facility <br /> or activity will be billed to the Party identified as the OWNER on this form l also certify that all operations will be Performed in accordance with all applicable Ordinance Codes andfor Standards and State anclor <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 Rete' y <br /> REHS: Date�_/42 Account out: Dati / <br /> COMMENTS: t1 7/ p <br /> rn� /� I�1 ,.� Pih2orJCi <br /> <i• 1j yr �i-w,.— -j L(J ( C rrr/Fr^N AV, <br /> �oz � Iu-11 , J cicloQw54 �Ir, <br />