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Date run 3/10/2014 10.17:36AI SAN JO.,. JIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report OW21 <br /> Run by <br /> Facility Information as of 3/10/2014 Pagel <br /> Record Selection Criteria: Facility ID FA0005863 <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 OW0004667 New Owner ID <br /> Owner Name STOCKTON ROOFING COMPANY <br /> Owner DBA STOCKTON ROOFING CO INC <br /> Owner Address 2712 E FREMONT ST <br /> STOCKTON, CA 95205 <br /> Home Phone 209-466-5951 <br /> Work/Business Phone 831-373-4383 <br /> Mailing Address PO BOX 1169 <br /> STOCKTON, CA 95201 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0005863 10181957 <br /> Facility Name STOCKTON ROOFING COMPANY <br /> Location 2712 E FREMONT ST <br /> STOCKTON, CA 95205 <br /> Phone 209-466-5951 x0 <br /> Mailing Address PO BOX 1169 <br /> STOCKTON, CA 95201 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 14343060 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 AR0006706 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name STOCKTON ROOFING COMPANY (Circe One) <br /> Account Balance as of 3/10/2014: $290.00 <br /> (Circe One) <br /> Transfer to Activellnacive <br /> ProgranvElement and Description Record ID Employee ID and Name Status New OwneR Delete <br /> 1921 -HMBP-Regular-Primary Location PR0519477 EE0006044-LOWELL ALLEN Active Y N A L D <br /> 2220-SM HW GEN<5 TONSNR PRO530330 EE0009488-JEFFREY WONG Inactivc Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO611515 EE0000000-HAZ MAT SJC OES Inactivc Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0503487 EE0000008-LETITIA BRIGGS Inactivc Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509227 EE0000000-HAZ MAT SJC OES Inactivc Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534618 Inactivc Y N 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,PHSrEHO hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on his form. I also car ify that all operations will be performed in accordance with all applicable Ordinance Codes ardor Standards and State andlor <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 <br /> RENSDate / / Acccunt out: Date, /�_/ <br /> COMMENTS: <br /> 1 2.yv��A q p� kl h cz jAll <br /> a�J S a-(Ie� PW 2ZI q <br />