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Date run 3/6/2015 2:35:11 PM SAN JO#IN CObNTY ENVIRONMENTAL HEA Report#5021 <br /> DEPARTMENT Pagel <br /> Run by <br /> Facility Information as of 3/6/2015 <br /> Record Selection Criteria: Facility ID FA0020071 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) (o <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0016479 New Owner ID <br /> Owner Name COBB, RYAN P <br /> Owner DBA CLUTCHES N MORE INC <br /> Owner Address 1057 SPRINGOAK WAY <br /> STOCKTON, CA 95209 <br /> Home Phone 209-478-8331 <br /> Work/Business Phone 209-478-8331 <br /> Mailing Address 1057 SPRINGOAK WAY <br /> STOCKTON, CA 95209 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0020071 10187499 <br /> Facility Name CLUTCHES N MORE <br /> Location 4629 N WEST LN <br /> STOCKTON, CA 95210 <br /> Phone 209-478-8331 x <br /> Mailing Address 1057 SPRINGOAK WAY <br /> STOCKTON, CA 95209 <br /> Care of COBB, RYAN P <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002-MILLER, KATHERINE Fax <br /> APN 10437014 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone Q - t`r NQVj <br /> ACCOUNTS RECEIVABLE FILE INFORMATION \ Ir,1 ok <br /> Account ID AR0035795 I, n I yl New Account ID: <br /> Mail Invoices to Facility V'0" Mail Invoices to: Owner / Facility / Account <br /> Account Name CLUTC MORE �oL� 11� ��) r , (Circle One) <br /> Account Balance as of 3/6/2015: Y' �7r/� <br /> (Circle One) <br /> 1 J Transfer to ActivelinacN/InacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0539195 EE0000006-HAZA SAEED Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0531158 EE0000005-FATINAH ZAREEF Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534056 Inactiv( Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor preject speck,PHSIEHD 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 ander Standards and State endcr <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 /> Paymente Check Number Receive by <br /> REH,S ��)—/ �"{�-�' Date _/ / Account out: Date <br /> COMMENTS. I _ <br />