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Date run 5/13/2016 9:52:17AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 5/13/2016 Record Selection Criteria: Facility ID FA0010153 OWNER FILE INFORMATION Number of facilities for this owner : 2 Owner ID OW0008153 Case Number: H06924 Owner Name WNGELET, ROGER Owner DBA SAHARGl71V-PLU`MI3lNG INC OwnerAddress 2216 STEWART ST EE0000006 - HAZA SAEED STOCKTON, CA 952053232 Home Phone 209-482=169&7 Work/Business Phone 2-99-474-26-" Mailing Address 2216 STEWART ST EE0000451 - STEVE SASSON STOCKTON, CA 95205 Care of N FACILITY FILE INFORMATION Facility ID / CERS ID FA0010153 10183269 Facility Name_ SAHARGU-N-"PLUMBIr4G tNC Location 2216 STEWART ST STOCKTON, CA 95205 Phone-209---474--26Y1—X0 Mailing Address 2216 STEWART ST STOCKTON, CA 952053232 Care of Location Code 99 - UNINCORPORATED A BOS District 002 - MILLER, KATHERINE APN 11908014 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0017153 Mail Invoices to._ Owner l-G"J Account Name VIN_C.ELET, ROGER 4 ,A}, , t Scab Account Balance as of 5/13/2016: $381.50 2 Program/Element and Description ray/(, DU T 3 RecD 1921 - HMBP-Reqular-Primary Location PR0520105 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512441 2381 - UST FACILITY (BEFORE 1/84) - obsolete PR0502940 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FE PR0510153 ERSC - ELECTRONIC REPORTING STATE SURCHARGE PRO533867 Make changes/corrections in RED ink. r INFORMATION CHANGE (date) 1� O OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : 0'i, Site Mitigation Facility Alt Phone Fax EMail : New Account ID: : Mail Invoices to: Owner / Facility / Account (Circle One) (Circle One) Active/Inactve Delete 1 J D �" D A I D A I D 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 t 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 andlor 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 Type Check Number Received by EHD Staff: Gl Date/ y?, / _ Account out: _4_ Date S / 1-7 4 COMMENTS: f Invoice* 02 -! cl,2 ?J Z G" .M �`` `'' ; �U `� 'b.Zt, �� f ..t\ \'� v,s • u�S S �c �( d "�� C� � Transfer to Employee ID and Name Status New Owner? EE0000006 - HAZA SAEED Inactive Y N EE0000000 - HAZ MAT SJC OES Inactive Y N EE0000451 - STEVE SASSON Inactive Y N EE0000000 - HAZ MAT SJC OES Inactive Y N Inactive Y N (Circle One) Active/Inactve Delete 1 J D �" D A I D A I D 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 t 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 andlor 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 Type Check Number Received by EHD Staff: Gl Date/ y?, / _ Account out: _4_ Date S / 1-7 4 COMMENTS: f Invoice* 02 -! cl,2 ?J Z G" .M �`` `'' ; �U `� 'b.Zt, �� f ..t\ \'� v,s • u�S S �c �( d "�� C� �