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Dale run 2/4/2015 3:30:12PM SAN JC�UIN COUNTY ENVIRONMENTAL HEA.I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/4/2015 <br /> Record Selection Criteria: Facility ID FA0021922 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br /> Owner ID OW0013110 New Owner ID <br /> Owner Name Kirk Sanders <br /> Owner DBA TUFFSHED <br /> Owner Address 2829 S HIGHWAY 99 RD <br /> STOCKTON, CA 95215 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-321-9548 <br /> Mailing Address 2754 Teepee Dr Ste B <br /> Stockton, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0021922 10614430 <br /> Facility Name Tuff shed 130 <br /> Location 2754 Teepee Dr Ste B <br /> Stockton, CA 95205 <br /> Phone 209-321-9548 x <br /> Mailing Address 2754 Teepee Dr Ste B <br /> Stockton, CA 95205 <br /> Care of Kirk Sanders <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 002- RUHSTALLER, LARRY Fax <br /> APN 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 AR0039949 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Kirk Sanders (Circle one) <br /> Account Balance as of 2/4/2015: $105.00 <br /> (Circle One) <br /> Transfer to Actioarnactve <br /> re lament and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1 0-HMBP-Common Materials PR0537976 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andbr 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 andlor Standards and State andfor <br /> Fed..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 /> REHS: <br /> Payment Type Check Number Date 2 / 4 / Acwunt out: Receiv Date / /L <br /> COMMENTS: <br />