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Date run 5/2/2017 10:37:40AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 5/2/2017 Record Selection Criteria: Facility ID FA0011064 OWNER FILE INFORMATION Number of facilities for this owner: 3 Owner ID OW0008526 Case Number: H08276 Owner Name KELLY REILLY Owner DBA Owner Address 5942 ST ANDREWS DR 209-670-7750 x0 STOCKTON, CA 95219 Home Phone 209-670-7750 Work/Business Phone 209-670-7750 Mailing Address PO BOX 7155 Y STOCKTON, CA 95267-0156 Care of KELLLYS EXPRESS CARWASH LLC FACILITY FILE INFORMATION Facility ID / CERS ID FA0011064 10184077 Facility Name KELLYS EXPRESS WASH Location 8610 THORNTON RD STOCKTON, CA 95209 Phone 209-670-7750 x0 Mailing Address PO BOX 7155 STOCKTON, CA 95267-0156 Care of KELLLYS EXPRESS CARWASH LLC Location Code Y BOS District APN 07242017 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail : Account ID AR0018064 New Account ID: Mail Invoices to Account Mail Invoices to: Owner / Account Name KELLYS EXPRESS WASH Account Balance as of 5/2/2017: $0.00 Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1921 - HMBP-Regular-Primary Location PR0520644 EE0008709 - JAMIE LIMA Active Y N AD PI 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513352 EE0000000 - HAZ MAT SJC OES Inactive Y N A D 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0511064 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO533231 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: ' $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Tyqe Check Number Received yOtl_ EHD Staff: Date Account out: Date /T/� COM ENT�I Invoice #: