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Date run 1/13/2015 4:04:37PN SAN JC UIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1/13/2015 <br /> Record Selection Criteria: Facility ID FA0015115 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0012096 Case Number: H07000 New Owner ID : <br /> Owner Name 139 EXPRESS ENTETZPRTS�� <br /> a.� <br /> Owner DBAcyn �cc t=AITCC7DAICCC <br /> Ov�.i ic�v <br /> Owner Address 3798 S HWY 99 <br /> STOCKTON, CA 95215 <br /> Home Phone 86&--t5A7-0782— c,4* 1 16� <br /> Work/Business Phone Not Specified <br /> Mailing Address 3798 S HWY 99 <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0015115 <br /> Facility Name HS EX S5 ENTERPRfSf-S <br /> Location 3798 S HWY 99 <br /> STOCKTON, CA 95215 <br /> Phone 8ee g- S59— "'F�f/ <br /> Mailing Address 3798 S HWY 99 <br /> STOCKTON, CA 95215 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 17917132 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 AR0025918 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name US EXPRESS ENTERPRISES (Circle One) <br /> Account Balance as of 1/13/2015: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0522824 Inactive Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0522169 EE0001421 -STACY RIVERA Inactive Y N— I D <br /> 3122-STORMWATER INSPECTION-AUTO SHOP PR0524554 EE0001421 -STACY RIVERA Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0535049 EE0002620-ALFONSO ARAMBULA Inactive Y N A I D <br /> 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 <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 and/or Standards and State andror <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 Date <br /> Payment Type Check Number Received y <br /> REHS: Date /1�/�15 Account out: Date / 115 <br /> COMMENTS: / <br />