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Date run 12/27/2016 3:37:34P <br /> Run by SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Facility Information as of 12/27/2016 Pagel <br /> Record Selection Criteria: FacilityID FA0005880 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) / 1� <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0004681 Case Number: H10064 New Owner ID : <br /> Owner Name _ � �, —r L-)A., <br /> :Fc <br /> Owner DBA EZ@t <br /> Owner-Address 601 S VENTURA V V, <br /> STOCKTON, CA 5203 <br /> Home Phone Not Specified <br /> Work/Business Phone 1211-7-787n--24tt— <br /> Mailing Address <br /> Care of PS BAJWA Inc. <br /> FACILITY FILE INFORMATION Office(209)467-1195 <br /> Facility ID/CERS ID FA0005880 10181967 CELL (209)470-6062 <br /> Facility Name 601 S VENTURA AVE <br /> Location 601 S VENTURAAVE STOCKTON, CA 95203 <br /> STOCKTON, CA 95203 Paul Bgjwa <br /> Phone 209-469-0810 X OWNER <br /> Psbajwa@livecom <br /> Mailing Address f�-g�jE 961 B— <br /> Care of �q <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 14509001 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 AR0006743 NewAccount ID: <br /> Maillnvoicesto 'OW I'Tt' Ac. Vail Invoices to: Owner / Facility / Account <br /> Account Name �1� (Circle One) <br /> Account Balance as of 12/27/2016: $0.00 1`J <br /> (Circle One) <br /> Program/Element and Description Record 10 Em to ea ID and Name Status Transfer to Acbt nactve <br /> P Y New Owner? Delete <br /> 1920-HMBP-Common Materials PRO520974 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO517607 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PRO503560 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0517611 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO524627 EE0000060-JENNIFER FRASE Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0531781 Inactive Y N A I D <br /> BILLING and COMPLIANCEACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acimowletlge that all site,and/or projeU specific,PHS/EHD hourly charges associated with this fac iffy <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 antl State ander <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Typ Check Number Received b <br /> EHD Staff: Z Date ! L /_2`/J�_ Account out: y Date <br /> COMMENTS: <br /> Invoice#: <br />