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Date run 6/1612014 11:19:38AI SAN JO�LTIN COUNTY ENVIRONMENTAL HEA DEPARTMENT <br /> Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/16/2014 <br /> Record Selection Criteria: Facility ID FA0010815 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN/Fed Tax ID <br /> Owner ID OW0008815 Case Number: H08803 New Owner ID <br /> Owner Name KITTO, JEFF <br /> Owner DBA PARKWOODS CLEANERS <br /> Owner Address 3307 FAIRWAY DR <br /> STOCKTON, CA 95204 <br /> Home Phone 209-946-0763 <br /> Work/Business Phone 209-478-1408 <br /> Mailing Address 3307 FAIRWAY DR <br /> STOCKTON, CA 95204 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0010815 10183839 <br /> Facility Name PARKWOODS CLEANERS <br /> Location 1901 COUNTRY CLUB BLVD <br /> STOCKTON, CA 952044821 <br /> Phone 209-464-2181 <br /> Mailing Address 3307 FAIRWAY DR <br /> STOCKTON, CA 95204 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 12315416 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account iD AR0017815 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility I Account <br /> Account Name PARKWOODS CLEANERS (Circle One) <br /> Account Balance as of 6/16/2014: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0520503 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONSIYR PRO514425 EE0004636-GARRETT BACKUS Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513103 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510815 EEo000000-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 PR0533364 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,ardlor project specific,PHS1EHD hourly charges associated with this facility <br /> or activity will he 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 andfor Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date ! 1 <br /> Water System to be TRANSFERED: Amount Paid Date ! I <br /> Payment Type Check Number Received by <br /> REHS: Date l 1 Account out: Date 1 1 <br /> COMMENTS: <br />