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Date run 1/28/2015 9:42:40AAReport x5321 <br /> SAN JO UIN COUNTY ENVIRONMENTAL HEA DEPARTMENT <br /> Run by Pagel <br /> Facility Information as of 1/28/2015 <br /> Record Selection Criteria: Facility ID FA0010282 <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 OW0008282 New OWnerID <br /> Owner Name MANUEL H SOUSA <br /> Owner DBA SOUSA'S CUSTOM HARVESTING <br /> Owner Address 20178 E GAWNE RD <br /> STOCKTON, CA 95215 <br /> Home Phone Not Specified <br /> WorkBusiness Phone 209-321-9359 <br /> Mailing Address 20178 E GAWNE RD <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0010282 10183403 <br /> Facility Name SOUSAS CUSTOM HARVESTING <br /> Location 20178 E GAWME RD <br /> STOCKTON, CA 95215 <br /> Phone 209-467-4122 x <br /> Mailing Address 20178 E GAWNE RD <br /> STOCKTON, CA 95215 <br /> Care of Manuel H. Sousa <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOIS District 004 -VOGEL, KEN Fax <br /> APN 18510003 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017282 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name MANUEL H SOUSA (Circle Of1e) <br /> Account Balance as of 1/28/2015: $0.00 <br /> (Circle One) <br /> Transfer to Activellnacme <br /> Program/Element and Description Record ID Employee ID and Name Status New owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0520231 EE0008709-JAMIE DE LA ROSA Active Y N A J„ D <br /> 1958-HM-Farm Operations PR0524837 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2221 -USED OIL ONLY-<5 TONS/YR PR0523576 EE0001421 -STACY RIVERA Active Y N A D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO512570 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510282 EE0000000-HAZ MAT SJC DES Inactive Y N A 1 D <br /> 2832-AST FAC 10 K-</=100 K GAL CUMULATIVE PR0523479 EE0001421 -STACY RIVERA Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO535786 EE0002622-BENJAMIN ESCOTfO Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532503 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the parry identified as the OWNER on this forml also certify that ell operations will be performed in accordance with all applicable Ordinance Codes anNor Standards and State and" <br /> Federal L. <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 fT�yp,, Check Number R y <br /> REHS: l—)tI <br /> , rDate Account out: Date L1z�/­y5— <br /> COMMENTS: FayOpef�-hV) IQ5 auf For a-AICunUy1Col^ V —a&Ss .)0 C „� J !” �J"e <br /> ft�y- <br />