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Date nm 4/27/2015 2:30:18PN SAN JOIN COUNTY ENVIRONMENTAL HEALf EPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 4/27/201 <br /> Records election Criteria: Facility ID FA0015572 <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: 1 SSNI Fed Tax ID <br /> Owner ID OW0012521 New Owner ID <br /> Owner Name HOME SUPPLY TOOL RENTAL & SALE <br /> Owner DBA HOME SUPPLY TOOL RENTAL&SALE <br /> owner Address 2377 E WATERLOO RD <br /> STOCKTON, CA 952052952 <br /> Home Phone 209-473-7483 <br /> Work/Business Phone 209465-2693 <br /> Mailing Address 2377 E WATERLOO RD <br /> STOCKTON, CA 95205-2952 <br /> care of SEVERIN & KISHI COMPANY INC <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0015572 10184991 <br /> Facility Name HOME SUPPLY TOOL RENTAL&SALES <br /> Location 2377 E WATERLOO RD <br /> STOCKTON, CA 95205-2952 <br /> Phone 209-465-2693 x <br /> Mailing Address 2377 E WATERLOO RD <br /> STOCKTON, CA 95205-2952 <br /> care of Sherman Serverin <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 11913017 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 AR0026872 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name HOME SUPPLY TOOL RENTAL & SALES (Circle One) <br /> Account Balance as of 4/27/2015: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactme <br /> PrograMElement and Description Record ID Employee ID and Name status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO625751 EE0000006-HAZA SAEED Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO524298 EE0000027-CINDY VO Active Y N A I D <br /> 3122-STORMWATER INSPECTION-AUTO SHOP PRO523072 EE0009488-JEFFREY WONG Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533382 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSEHD 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 andor Standards and State andor <br /> Federal Laws, <br /> APPLICANT'S 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 />