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Date run 1/9/2015 2:35:08PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 119/2015 <br />Record Selection Criteria: Facility Ill FA0014432 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0011474 <br />Owner Name <br />JIM CREEL <br />Owner DBA <br />WILD HORSES 4X4 <br />Owner Address <br />640 N EL DORADO ST <br />STOCKTON, CA 952023721 <br />Home Phone <br />Not Specified. <br />WorklBusiness Phone <br />209-644-6033 <br />Mailing Address <br />640 N EL DORADO ST <br />STOCKTON, CA 95202-3721 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID I CERS ID <br />FA0014432 10184663 <br />Facility Name <br />WILD HORSES 4X4 <br />Location <br />640 N EL DORADO ST <br />STOCKTON, CA 95202-3721 <br />Phone <br />209-943-0991 x0 <br />Mailing Address <br />640 N EL DORADO ST <br />STOCKTON, CA 95202-3721 <br />Care of <br />Jim Creel <br />Location Code <br />BOS District <br />001 - VILLAPUDUA <br />APN <br />13906004 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0024512 <br />Mail Invoices to Owner <br />Account Name JIM CREEL <br />Account Balance as of 11912015: $0.00 <br />Make changesicorrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />1 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 Activellnactve <br />Program/Element and Description Record ID Employee I❑ and Name Status New Owner? Delete <br />1921 - HMBP-Reqular-Primary Location PRO519290 EE0009817 - ROBERT LOPEZ Active Y N A D <br />2220 - SM HW GEN <5 TONS/YR PRO538476 EE0009488 - JEFFREY WONG Active Y N A D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO633011 InactivE Y N A D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT. I, the undersigned owner, operator or agent of same, acknowledge that all site, and project specific, PkSiEHD 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 arlor <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date 1 I <br />Program Records to be TRANSFERED: ` $25.00 = Amount Paid Date / / <br />Water System to be TRANSFERED: Amount Paid Date 1 ! <br />Payment T p.Uyw,�, e Check Number Receive by <br />REHS: XCr�tilts2 , Date /— t ! _ Account out: Date 1 1 15 ! <br />COMMENTS.. <br />