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Date run 5/3/2017 9:41:42AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 5/3/2017 <br />Record Selection Criteria: Facility ID FA0009631 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID <br />OW0007631 Case Number: H05020 <br />Owner Name <br />JARVIS, JEFFREY <br />Owner DBA <br />JARVIS KUSTOMS INC <br />Owner Address <br />6763 VICKSBURG PL <br />209-992-750_ <br />STOCKTON, CA 95207 <br />Home Phone <br />209-992-7503 <br />Work/Business Phone <br />209-992-7503 <br />Mailing Address <br />6763 VICKSBURG PL <br />01-STOCKTON <br />STOCKTON, CA 95207 <br />Care of <br />JARVIS, JEFFREY <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0009631 10689295 <br />Facility Name <br />JARVIS KUSTOMS <br />Location <br />845 S COMMERCE St <br />EE0000000 - HAZ MAT SJC OES <br />STOCKTON, CA 95206 <br />Phone <br />209-992-750_ <br />Mailing Address <br />6763 VICKSBURG PL <br />STOCKTON, CA 95207 <br />Care of <br />JARVIS, JEFFREY <br />Location Code <br />01-STOCKTON <br />BOS District <br />001 - VILLAPUDUA, CARLOS <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name JARVIS, JEFFREY <br />Title MANAGER <br />Day Phone 209-992-7503 <br />Night Phone 209-992-7503 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0016631 <br />Mail Invoices to Account (� <br />Account Name JARVIS KUSTOMS. <br />Account Balance as of 5/3/20Z$824Pro ram/Element and Descri tion RecordV <br />9 P921 - HMBP-Reqular-Primary LocaPR0519784 <br />2220 - SM HW GEN <5 TONS/YR PR0538423 <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511919 <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PRO509631 <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0534037 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax ILI_,il/7V/t'/ <br />Employee ID and Name <br />New Account ID: <br />Mail Invoices to: Owner / <br />Status <br />Facility / Account <br />(Circle One) <br />Transfer to <br />New Owner? <br />EE0009817 - ROBERT LOPEZ <br />Active <br />Y N <br />EE0000026 - CESAR RUVALCABA <br />Active <br />Y N <br />EE0000000 - HAZ MAT SJC OES <br />Inactive <br />Y N <br />EE0000000 - HAZ MAT SJC OES <br />Inactive <br />Y N <br />Inactive <br />Y N <br />(Circle One) <br />Active/I nactve <br />Delete <br />AD <br />A D <br />A I D <br />A I D <br />A 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 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 and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: Date S / '? 7 <br />Program Records to be TRANSFERED: * $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment TypeC eck Number Received by _ <br />EHD Staff: Date _ / /—a Account out: U6 Date 5/ 3 /� <br />COMMENTS: <br />Invoice #: <br />