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Dae m^ 1!9/2015 2:35:08PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Run M Report#5021 <br /> Facility Information as of 1/9/2015 Pagel <br /> Record Selection Criteria: Facility ID FA0014432 <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 <br /> SSN/Fed Tax ID <br /> Owner ID OW0011474 New Owner ID <br /> Owner Name JIM CREEL <br /> Owner DBA WILD HORSES 4X4 <br /> Owner Address 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 lD/CERS ID FA0014432 10184663 <br /> Facility Name WILD HORSES 4X4 <br /> Location 640 N EL DORADO ST <br /> STOCKTON, CA 95202-3721 <br /> Phone 209-943-0991 xO <br /> Mailing Address 640 N EL DORADO ST <br /> STOCKTON, CA 95202-3721 <br /> Care of Jim Creel <br /> Location Code Alt Phone <br /> BOS District 001 -VILLAPUDUA 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 /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name JIM CREEL (Circle One) <br /> Account Balance as of 1/9/2015: $0.00 <br /> (Circle One) <br /> Transfer to A e/Inactve <br /> Program/Element and Descnption Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO519290 EED009817-ROBERT LOPEZ Active Y N A D <br /> 2220-SM HW GEN<5 TONS/YR PR0538476 EE0009488-JEFFREY WONG Active Y N ACali D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533011 Inactive Y N A D <br /> BILLING ars!COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent a same,acknowledge that all site,ai project specii c,PHSEHD hourly charges associated with this facility <br /> oractivily will be billed to Ne party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes ani Standards and State ands <br /> Federal Lewis <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 pe �.. n .C..h,eck Number Receive by <br /> RENS: Wlrl LE.V ucYA Date / / Account out: Date <br /> COMMENTS: <br /> TOQC,'l:WOd, • ��.S;«rSS r`�10v2G� � I(7y5 S. Cre,C'pkCL L-ct�� <br />