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Date tun 10/10/2014 4:25:34F SAN JO�JIN COUNTY ENVIRONMENTAL HEAL'DEPARTMENT Repottt5021 <br /> Runby Pepsi <br /> Facility Information as of 10/10/2014 <br /> Record Selection Criteria: Facility ID FA0016278 <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: 2 SSN/Fed Tax ID <br /> Owner ID OW0002824 New Owner ID <br /> Owner Name BROADBASE INC. <br /> Owner DBA JIFFY LUBE#1478 (HAMMER) <br /> Owner Address 1700 N BROADWAY <br /> WALNUT CREEK, CA 94596 <br /> Home Phone-209_957--&7te- �r L <br /> Work/Business Phone 916-375-1155 <br /> Mailing Address 1471 SHORE ST <br /> WEST SACRAMENTO, CA 95691 <br /> Care of BROADBASE INC dba JIFFY LUBE <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0016278 10185139 <br /> Facility Name JIFFY LUBE#1478 <br /> Location 1648 E HAMMER LN <br /> STOCKTON, CA 95210 <br /> Phone <br /> 209-957-8-73t}-x <br /> Mailing Address 1471 SHORE ST <br /> WEST SACRAMENTO, CA 95691 <br /> Care of BROADBASE INC <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District Fax <br /> APN 09428014 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 AR0028468 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name JIFFY LUBE#1478 (Circle One) <br /> Account Balance as of 10/10/2014: $0.00 <br /> (Circe One) <br /> Program/Element and Descdptian Record ID Em to ee ID and Name StaNs Transfer to Acvve/lnadve <br /> P Y New Owner/ Delete <br /> 1921 -HMBP-Regular-Primary Location PRO524482 EE0000006-HAZA SAEED Active Y N A I D <br /> 2229-GEN 50<250 TONS PERMIT PR0524254 EE0000005-FATINAH ZAREEF Active Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PRO527167 EE0000005-FATINAH ZAREEF Active,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533756 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent of same,=knowledge that all site,andor project specific,PHSIEHD hourly charges associated with this faUdy <br /> or activity will be billed to the party identified as the OWNER m this form. I also canny that all operations will be performed in a=rdarke with all applicable Ordinance Codes ander Standards and Slate andor <br /> Federal Laws /�L J <br /> APPLICANTS SIGNATURE: II/ �cit es— 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 Reoely d <br /> REHS: Date_/ / Account out: — Date / l <br /> COMMENTS: _ <br />