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Date run 11412013 2:15:31 PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 114!2013 <br /> Record Selection Criteria: Facility ID FAOC14455 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN 1 Fed Tax ID <br /> Owner ID O'W0011497 New Owner ID <br /> Owner Name CARL CRUTCHFIELD <br /> Owner DBA CARL CRUTCHFIELD CONST CO <br /> Owner Address 2655 E MINER AVE <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-931-9287 <br /> Mailing Address PO BOX 8870 <br /> STOCKTON, CA 95208 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014455 <br /> Facility Name CARL CRUTCHFIELD CONST CO <br /> Location 2655 E MINER AVE STE B <br /> STOCKTON, CA 95205 <br /> Phone 209-943-6812 x0 <br /> Mailing Address 2655 E MINER AVE STE B <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 14343023 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 AR0024535 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to Owner I Facility I Account <br /> Account Name CARL CRUTCHFIELD (Circle One) <br /> Account Balance as of 11412013: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramlElemenl and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0519313 EE0000000-HAZ MAT SJC OES Active Y N A I <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0534442 Inactive Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENTS I,the undersigned owner,,operator or agent of same,acknowledge that all site,and/or project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be bulled 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 andor <br /> Federal Laws <br /> APPLICANT'S SIGNATURE: Date I ! <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date I I <br /> Water System to be TRANSFERED: Amount Paid Date I 1 <br /> Payment Type Check Number Received by <br /> RENS: Date I Account out: t,1, Date / 1� <br /> ;7� <br />