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Date tun 8/16/2018 8:38:35AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/16/2018 <br /> Record Selection Criteria Facility ID FA0009034 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) l <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : <br /> Owner ID OW0007034 New Owner ID <br /> Owner Name ROGERS, E J <br /> Owner DBA ELEMENT LANDSCAPE MATERIALS <br /> Owner Address 3487 E MUNFORD AVE <br /> STOCKTON, CA 95215 <br /> Home Phone 209-464-8701 <br /> Work/Business Phone 209-464-8701 <br /> Mailing Address PO BOX 32314 <br /> STOCKTON, CA 95213 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0009034 10182361 <br /> Facility Name ELEMENT LANDSCAPE MATERIALS <br /> Location 3487 E MUNFORD AVE <br /> STOCKTON, CA 95215 <br /> Phone 209-464-8701 x <br /> Mailing Address PO BOX 32314 <br /> STOCKTON, CA 95215 <br /> Care of ELEMENT LANDSCAPE MATERIALS <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 17955024 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016034 New AccountlD: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name ELEMENT LANDSCAPE MATERIALS cCircleOne) <br /> Accou Balance as of 8/16/2018: $0.00 <br /> (Circle One) <br /> Transferto Active/Inectve <br /> Pr ra ement and Description Record ID Employee ID and Name Status New OwneR Delete <br /> 1 7 -HMBP-Reqular-Primary Location PRO520920 EE0008709-JAMIE LIMA Active Y N A I D <br /> 222 HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511322 EEOoo00o0-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO509034 EE00o0000-HAZ MAT SJC DES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0527340 EE0004486-ANGELICA SANDOVAL MARII Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0534745 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent W same,acknowledge that all site,andvor project specific,PHSEHD hourly charges associated with this facility <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 anclor Standards and State and'or <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Ty p ' Check Number Received <br /> EHD Staff: lJl V V V/f Date / / Account out: y Date <br /> OMMENTS: <br /> ,� n p,� t,,,y p 1nV01Ce#: <br />