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Date run 9/1/2015 4:29:21 PM SAN JO/ IN COUNTY ENVIRONMENTAL HEAL )EPARTMENT Report#5021 Run by Pagel Facility Information as of 9/1/2015 Record Selection Criteria: Facility ID FA0010054 OWNER FILE INFORMATION Number of facilities for this owner: 1 Owner ID OW0008054 Owner Name BEAS, JOSE Owner DBA SANTA CLARA AUTO SALES Owner Address 2147 E LAFAYETTE AVE Mailing Address STOCKTON, CA 95205 Home Phone 209-944-5784 Work/Business Phone 209-430-2511 Mailing Address 2147 E LAFAYETTE BOS District STOCKTON, CA 95205 Care of BEAS, JOSE FACILITY FILE INFORMATION Facility ID / CERS ID FA0010054 10183165 Facility Name SANTA CLARA AUTO SALES Location 1248 E MINER AVE STOCKTON, CA 95205 Phone 209-944-5701 x Mailing Address 2147 E LAFAYETTE Active STOCKTON, CA 95205 Care of jose beas Location Code 01-STOCKTON BOS District 001 - VILLAPUDUA, CARLOS APN 15116029 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail: Account ID AR0017054 Mail Invoices to Facility Mail Invoices to: Account Name SANTA CLARA AUTO SALES Account Balance as of 9/1/2015: $1,288.75 New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1920 - HMBP-Common Materials PR0521656 EE0000006 - HAZA SAEED Active Y N AlO D 2220 - SM HW GEN <5 TONS/YR PR0514146 EE0000027 - CINDY VO Active Y N A I D 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512342 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510054 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0533250 Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or 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 and/or 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 SCOMMPayment Type Check Number Received by EHD Staff: - — IDate c� / 7 Account out: Date / / IS— COMMENTS: ENTS: S v—S C\ c'X � Invoice #: a cr�.�.Q,