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Date run 10/5/2018 11:44:10AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 10/5/2018 Record Selection Criteria: Facility ID FA0012730 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0009916 Owner Name Margaret Gawrysiuk Owner DBA ROUTE 66 Owner Address 10727 MULBERRY AVE PR0521082 FONTANA, CA 92337 Home Phone Not Specified Work/Business Phone 909-744-5418 Mailing Address 6800 Santa Fe DR EE0000026 - CESAR RUVALCABA Hodgkins, IL 60525 Care of A FACILITY FILE INFORMATION 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION Facility ID / CERS ID FA0012730 10184331 Facility Name ROUTE 66 Location 781 SWIFT WAY 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F STOCKTON, CA 95206 Phone 103-5 x Mailing Address 6800 Santa fe dr, unit b2 I D Hodgkins, IL 60525 Care of ROUTE 66 Location Code 01 - STOCKTON BOS District 001 - VILLAPUDUA, CARLOS APN PRO532072 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0021248 Mail Invoices to Account Account Name on�$6 Lrz' Account Balance as of 10/5/2018: $211.00 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) 1 SSN / Fed Tax ID New Owner ID �Lt.vr�,! r�vn4 LAAS_ Alt Phone Fax EMail : Mail Invoices to: New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Aclive/Inaclve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1920 - HMBP-Common Materials PR0521082 EE0009817 - ROBERT LOPEZ Active Y N A I D 2220 - SM HW GEN <5 TONS/YR PR0516666 EE0000026 - CESAR RUVALCABA Inactive Y N A I D 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0517561 EE0000000 - HAZ MAT SJC OES InaCtIVE Y N A I D 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PRO516667 EE0000418 - MICHAEL KITH InaCtIVE Y N A I D 2832 - AST FAC 10 K - </=100 K GAL CUMULATIVE PR0528344 EE0000026 - CESAR RUVALCABA Inactive Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO532072 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: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: CnMMFNTS' PtA $25.00 = Date Amount Paid Date Amount Paid Date Received by Account out: 0 Date IV / Invoice #: