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Date run 11/2/2015 9:25:10AN SAN JOA IN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 11/2/2015 <br />Record Selection Criteria: Facility ID FA0005120 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0003998 <br />Owner Name <br />Kelly Reilly <br />Owner DBA <br />KELLEY'S EXPRESS CAR WASH <br />Owner Address <br />5942 SAINT ANDREWS DR <br />STOCKTON, CA 95219 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-670-7750 <br />Mailing Address <br />5942 SAINT ANDREWS DRIVE <br />STOCKTON, CA 95219 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0005120 10181739 <br />Facility Name <br />KELLEYS EXPRESS CAR WASH <br />Location <br />3300 N EL DORADO ST <br />STOCKTON, CA 95204 <br />Phone <br />209-475-9314 x <br />Mailing Address <br />5942 SAINT ANDREWS DRIVE <br />STOCKTON, CA 95219 <br />Care of <br />Kelly Reilly <br />Location Code <br />01-STOCKTON <br />BOS District <br />002 - MILLER, KATHERINE <br />APN <br />11515309 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0005566 <br />Mail Invoices to Account <br />Account Name KELLYS EXPRESS CAR WASH <br />Account Balance as of 11/2/2015: $0.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) ; <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Mail Invoices to <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Reqular-Primary Location PR0526823 EE0000006 - HAZA SAEED Active Y N A C- D <br />2381 - UST FACILITY (BEFORE 1/84) - obsolete PR0501488 EE0000451 - STEVE SASSON Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0532557 Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENTS I, the undersigned owner, operator or agent 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 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 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Type Check Number Received by <br />EHD Staff: t kc" Date ��/ z /� Account out: L Y Date Z 1--71 / 1-S <br />COMMENTS: <br />Invoice #: <br />