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Date run 6/2/2016 12:39:46PM SAN JOAQU:11Lf'01--iNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by (brown Pagel Facility Information as of 6/2/2016 Record Selection Criteria: Facility ID FA0010935 OWNER FILE INFORMATION Number of facilities for this owner: 1 Owner ID OW6008935 Case Number: H09002 Owner Name J Owner DBA Owner Address 1630 N WILSON WAY STOCKTON, CA 95205 Home Phone Not Specified Work/Business Phone Mailing Address 1630 N WILSON WAY STQCKTON, CA 95205 Care of FACILITY FILE INFORMATION Facility ID / CERS ID FA0010935 10183949 Facility Name J Location 1630 N WILSON WAY STOCKTON, CA 95205 Phon _ _ X Mailing Address Careof ,'-------- Location Code 99 - UNINCORPORATED P BOS District 002 -MILLER, KATHERINE APN 11727026 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name JOSE LOPEZ Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0017935 Employee ID and Name Mail Invoices to Account xp \ �O Account Name__J&G—A-U-T- "0707 Account Balance as of 6/2/2016: $621.00 Program/Element and DescriptionRecord ID 1920 - HMBP-Common Materials �� PRO520558 2220 - SM HW GEN <5 TONS/YR PRO514462 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513223 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510935 3122 - STORMWATER INSPECTION - AUTO SHOP PRO522986 ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0533803 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) 44, jll�l��il�"11Rs.�l7j►I� Alt Phone Fax EMail:i - . • Ci e•Qe ROWMA UWAV31 Mail Invoices to: Qr,•�o �a�V^ New Account ID: : Owner / Facility / Account (Circle One) BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andlor 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 andtor Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: J2�%v' '�`' ' Date l) (a 03 / I b Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received by EHD Staff: i -)l1 Datey / > / Account out: Date COMMENTS: c Invoice #: �v � Y Y u (Circle One) Transfer to Active/Inactve Employee ID and Name Status New Owner? Delete EE0000006 - HAZA SAEED Active Y N A I D EE0000015 - TIMOTHY ENGLE Active Y N A I D EE0000000 - HAZ MAT SJC OES Inactive Y N A I D EE0000000 - HAZ MAT SJC OES Inactive Y N A I D EE0009488 - JEFFREY WONG Inactive Y N A I D Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andlor 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 andtor Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: J2�%v' '�`' ' Date l) (a 03 / I b Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received by EHD Staff: i -)l1 Datey / > / Account out: Date COMMENTS: c Invoice #: �v � Y Y u