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Date run 12/1/2014 12:05:08PI SAN JC '1IN COUNTY ENVIRONMENTAL HEA l DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 12/1/2014 <br />Record Selection Criteria: Facility ID FA0010153 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) 60t <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION Number of facilities for this owner: <br />2 SSN/Fed Tax ID <br />Owner ID OW0008153 Case Number: <br />H06924 New Owner ID <br />Owner Name VINCELET, ROGER <br />Owner DBA SAHARGUN PLUMBING INC <br />Owner Address 2216 STEWART ST <br />STOCKTON, CA 952053232 <br />Home Phone 209-482-1007 <br />Work/Business Phone 209-474-2611 <br />Mailing Address 2216 STEWART ST <br />STOCKTON, CA 95205 <br />Care of <br />FACILITY FILE INFORMATION <br />Site Mitigation Facility <br />Facility ID / CERS ID FA0010153 10183269 <br />Facility Name SAHARGUN PLUMBING INC <br />Location 2216 STEWART ST <br />STOCKTON, CA 95205 <br />Phone 209-474-2611 x0 <br />Mailing Address 2216 STEWART ST <br />STOCKTON, CA 952053232 <br />Care of <br />Location Code 99 - UNINCORPORATED P <br />Alt Phone <br />BOS District 002 - RUHSTALLER, LARRY <br />Fax <br />APN 11908014 <br />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 AR0017153 <br />New Account ID: <br />Mail Invoices to Owner <br />Mail Invoices to: Owner / Facility / Account <br />Account Name VINCELET, ROGER <br />(Circle One) <br />Account Balance as of 12/1/2014: $381.50 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID <br />Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Reqular-Primary Location PR0520105 <br />EE0000006 - HAZA SAEED Active Y N A (g D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512441 <br />EE0000000 - HAZ MAT SJC OES InaCtIVE Y N A I D <br />2381 - UST FACILITY (BEFORE 1/84) - obsolete PR0502940 <br />EE0000451 - STEVE SASSON InactivE Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510153 <br />EE0000000 - HAZ MAT SJC IDES InaCtIVE Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO533867 <br />InactivE Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent <br />of same, acknowledge that all site, and/or project specific, PHS/EHD 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 <br />will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: * $25.00 = <br />Amount Paid Date <br />Water System to be TRANSFERED: <br />Amount Paid Date <br />Payment Type Check Number <br />Received b f <br />REHS: ell Vi Date IA / <br />/ is Account out: Date <br />COMMENTS: <br />91 ,1 AO 19" VA 114 t IM Z—��� • �si�-v�i5 G1054 <br />