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Date run 5/22/2013 3:33:54PK SAN JC `UIN COUNTY ENVIRONMENTAL HEA "I DEPARTMENT Repor1N5021 <br /> Run by 4/ t%W01 Pagel <br /> Facility Information as of 5/22/2013 / <br /> Record Selection Criteria: Facility ID FA0009370 <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 OW0007370 Case Number: H03539 New Owner ID <br /> Owner Name ROSE, DOUG <br /> Owner DBA KUSTOM KURVES COLLISION REPAIR <br /> Owner Address 1412 ARUNDEL CT <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-334-6803 <br /> Mailing Address 4 N HOUSTON LN <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0009370 10,182,635 <br /> Facility Name KUSTOM KURVES COLLISION REPAIR <br /> Location 4 N HOUSTON LN <br /> LODI, CA 952402420 <br /> Phone 209-334-6803 <br /> Mailing Address 4 N HOUSTON LN <br /> LODI, CA 95240 <br /> Care of <br /> Location Code 02 - LODI Alt Phone <br /> BOIS District 004 -VOGEL, KEN Fax <br /> APN 04321040 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 AR0016370 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name KUSTOM KURVES COLLISION REPAIR (Circle One) <br /> Account Balance as of 5/22/2013: $0.00 <br /> (Circle One) <br /> Transfer to ActiveMactve <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO521023 EE0008709-JAMIE DE LA ROSA Active Y N A OI D <br /> 2220-SM HW GEN<5 TONSNR PR0513795 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511658 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509370 EE0000o00-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531645 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,PHS/EHD hourly charges associated with this faulity, <br /> 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 andor Standards and State andor <br /> Federal Laws, <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid D is <br /> Payment Tyge Cheqk Number Rece <br /> Date /Z/1,"')) Account out: Date /__4A/� <br /> 3u 'MC,SS VVAS sib �;�ieS of lr �r +s <br /> g� cut <br />