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Date run 7/20/2017 2:07:50PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Repo"#5021 <br /> Run by Pagel <br /> Facility Information as of 7/20/2017 <br /> Record Selection Criteria: Facility ID FA0014432 <br /> Make changeslcorrections 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 OW0011474 New Owner ID <br /> Owner Name JIM CREEL <br /> Owner DBA WILD HORSES 4X4 <br /> OwnerAddress 640 N EL DORADO ST <br /> STOCKTON, CA 952023721 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-644-6033 <br /> Mailing Address 640 N EL DORADO ST <br /> STOCKTON, CA 95202-3721 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0014432 10184663 <br /> Facility Name WILD HORSES 4X4 <br /> Location 640 N ELDORADO ST <br /> STOCKTON, CA 95202-3721 <br /> Phone 209-943-0991 x0 <br /> Mailing Address 640 N ELDORADO ST <br /> STOCKTON, CA 95202-3721 <br /> Care of Jim Creel <br /> Location Code Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 13906004 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 AR0024512 New Account ID: <br /> Maillnvoicesto Owner Mail l nvoices to: Owner / Facility / Account <br /> Account Name JIM CREEL (Circle One) <br /> Account Balance as of 7/20/2017: $0.00 <br /> (Circle One) <br /> Transferto Active/Inactve <br /> Program/Element and Description Record ID Employee 10 and Name Status New Owner! Delete <br /> 1921 -HMBP-Regular-Primary Location PR0519290 EE0009817-ROBERT LOPEZ Inactive ` Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0538476 EE0009488-JEFFREY WONG Inactive Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0533011 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge Nat all site,andror prolecl spectic,PHSfEHD hourly charges associated with this facility <br /> or activity will be billed to the party idenlned 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 anclor <br /> Federal Laws. <br /> APPLICANTS 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 Received by <br /> EHD Staff: Date / / Account out: Date / / <br /> COMMENTS: Invoice : <br />