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DAe run 11/4/2014 8:10:43AR SAN JO*IN COUNTY ENVIRONMENTAL HEAODEPARTMENT Report 05021 <br /> Run byPagel <br /> Facility Information as of 11/4/2014 <br /> Record Selection Criteria: Facility ID FA0003743 <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: 3 SSN/Fed Tax ID <br /> owner ID OW0000629 New Owner ID <br /> Owner Name Marion Canape <br /> Owner DBA CANEPAS CAR WASH <br /> Owner Address 642 N HUNTER ST <br /> STOCKTON, CA 95202 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-465-6114 <br /> Mailing Address 642 N HUNTER ST <br /> STOCKTON, CA 95202 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0003743 10181369 <br /> Facility Name CANEPAS LUBE & OIL <br /> Location 6220 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Phone 209-951-9772 x <br /> Mailing Address 6220 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> care of Chauncey Centeno <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOIS District 002 -RUHSTALLER, LARRY Fax <br /> APN 08136004 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 AR0003322 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name CANEPAS LUBE & OIL (Circle One) <br /> Account Balance as of 11/4/2014: $0.00 (Cirde One) <br /> Transfer to Activellname <br /> PrograMElemenl and Description <br /> Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0519739 EEGOO0006-HAZA SAEED Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO511864 EE0000000-HAZ MAT SJC IDES Inactive Y N A I D <br /> 2228-GEN 25<50 TONS PERMIT PRO513910 EE0000005-FATINAH ZAREEF Active Y N A I D <br /> 2332-EXEMPT TANK FACILITY PR0231224 EE0000005-FATINAH ZAREEF Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0507432 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PRO528058 EE0000005-FATINAH ZAREEF nett ve Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533416 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acnowledge that all site,andfor project specific,PHS/EHD hourly charges associated with this facility or, <br /> ba 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 andlor Standards and Stale anNor 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 Type Check Number Received by <br /> REHS: Date_/_/_ Account out: Date <br /> COMMENTS: <br />