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Date run 1/28/2016 12:46:33PI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 1/28/2016 Record Selection Criteria: Facility ID FA0011023 OWNER FILE INFORMATION Number of facilities for this owner: 3 Owner ID OW0007393 Case Number: H03711 Owner Name MORGANSON, DAVE Owner DBA Owner Address 3812 MONDRIAN DR MODESTO, CA 953562448 Home Phone Not Specified Work/Business Phone 209-678-0039 Mailing Address PO BOX 6463 STOCKTON, CA 95206 Care of COSLETT, RICK FACILITY FILE INFORMATION Make changes/corrections in RED ink. Z / INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN /Fed Tax ID New Owner ID : Facility ID / CERS ID FA0011023 10184043 Facility Name INTERSTATE TRUCK CTR - COLLISION DI Location 641 S Harrison St Stockton, CA 95203 Phone 209-467-3561 x Mailing Address PO BOX 6463 STOCKTON, CA 95206 Care of COSLETT, RICK Location Code Alt Phone BOS District Fax APN 14704047 EMail: EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0018023 New Account ID: Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account Account Name INTERSTATE TRUCK CTR - COLLISION DI (Circle One) Account Balance as of 1/28/2016: $0.00 (Circle One) Transfer to Active/Inactve Program Element and Description Record ID Employee ID and Name Status New Owner? Delete 1921 - HMBP-Reqular-Primary Location PR0520616 EE0009817 - ROBERT LOPEZ Active Y N A ( D 2220 - SM HW GEN <5 TONS/YR PR0514497 EE0001421 -STACY RIVERA Active Y N A I D 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513311 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0511023 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2840 - AST EXEMPT FAC < 1,320 GAL PR0528799 EE0001421 - STACY RIVERA Inactive Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0534024 Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andlor project specific, PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received b EHD Staff:T� st L Date / / 2- 'P/ Account out: �� Date COMMENTS: Invoice #: