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[Record <br /> te mn 10/10/2014 4.25:34F SAN JOS TIN COUNTY ENVIRONMENTAL HEAL\ ' DEPARTMENT <br /> n by Report#W21 <br /> Facility Information as of 10/10/2014 Pagel <br /> Selection Critena: Facility ID FA00I6278 <br /> Make changestcorrections in RED Ink. _ <br /> INFORMATION CHANGE(date) \\ -\N, <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br /> Owner ID OW0002824 New Owner ID <br /> Owner Name BROADBASE INC. <br /> Owner DBA JIFFY LUBE#1478 (HAMMER) <br /> Owner Address 1700 N BROADWAY <br /> WALNUT CREEK, CA 94596 <br /> Home Phone-289-957=87310- <br /> Work/Business Phone 916-375-1155 <br /> Mailing Address 1471 SHORE ST <br /> WEST SACRAMENTO, CA 95691 <br /> Care of BROADBASE INC dba JIFFY LUBE <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0016278 10185139 <br /> Facility Name JIFFY LUBE#1478 <br /> Location 1648 E HAMMER LN <br /> STOCKTON, CA 95210 <br /> Phone 209-957-8738 x <br /> Mailing Address 1471 SHORE ST <br /> WEST SACRAMENTO, CA 95691 <br /> Care of BROADBASE INC <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District Fax <br /> APN 09428014 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 AR0028468 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name JIFFY LUBE#1478 (Circle one) <br /> Account Balance as of 10/10/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description RecordID Employee ID and Name Status New Owner! Delete <br /> 1921 -HMBP-Regular-Primary Location PRO524482 EE0000006-HAZA SAEED Active Y N A I D <br /> 2229-GEN 50<250 TONS PERMIT PRO524254 EE0000005-FATINAH ZAREEF Active Y N A I D <br /> 2831 -AST FAC >/= 1,320-<10 K GAL CUMULATIVE PR0527167 EE0000005-FATINAH ZAREEF Active,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533756 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acl noWledge that all site.and/or project specific,PRSEND hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. 1 also certify that all operations will be performed in accordance with all applicable Ordinance codes and/or Standards and Slate ander <br /> Federal Laws <br /> APPLICANTS SIGNATURE: // �Gy, -. Date `k <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date / I <br /> Water System to be TRANSFERED: Amount Paid Date I / <br /> Payment Type Check Number Receiv <br /> REHS: Date / / Account out: Date I /� <br /> COMMENTS: 1 •�i^ ��r� <br />