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Date run 2/25/2016 11:43:23AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 2/25/2016 Record Selection Criteria: Facility ID FA0011064 Account Balance as of 2/25/2016: $320.00 (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 DE LA ROSA Active Y N A I D 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513352 EE0000000 - HAZ MAT SJC OES Inactive Y N A I 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: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS: * $25.00 = Amount Paid Date Amount Paid Date / ! Received by Date / / Account out: -��` Date l 5 l.6 /moi a .l\NS 4%Ac4 e%s GkgN Se " Pet- 1-t k v PFJ ^-; Invoice #: Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) OWNER FILE INFORMATION Number of facilities for this owner: 3 SSN/Fed Tax ID Owner ID OW0008526 Case Number: H08276 New Owner ID Owner Name KELLY REILLY Owner DBA Owner Address 5942 ST ANDREWS DR STOCKTON, CA 95219 Home Phone 209-670-7750 Work/Business Phone 209-670-7750 Mailing Address 5942 ST ANDREWS DR STOCKTON, CA 95219 Care of KELLLYS EXPRESS CARWA H 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 Q co Y, -7 S 01-J L A C -a - -� Care of Kelly Reilly Location Code / / Alt Phone BOS District / Fax APN 07242017 EMail: EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0018064 New Account ID: Mail Invoices to Account Mail Invoices to: Owner / Facility ! Account Account Name KELLYS EXPRESS WASH (Circle One) Account Balance as of 2/25/2016: $320.00 (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 DE LA ROSA Active Y N A I D 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513352 EE0000000 - HAZ MAT SJC OES Inactive Y N A I 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: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS: * $25.00 = Amount Paid Date Amount Paid Date / ! Received by Date / / Account out: -��` Date l 5 l.6 /moi a .l\NS 4%Ac4 e%s GkgN Se " Pet- 1-t k v PFJ ^-; Invoice #: