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Date run 1/29/2014 9:44:37AN SAN JO, SIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1/29/2014 <br /> Record Selection Criteria: Facility ID FA0014432 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) Z2 a L <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0011474 New Owner ID <br /> Owner Name JIM CREEL <br /> Owner DBA WILD HORSES 4X4 <br /> Owner Address 640 N EL DORADO ST <br /> STOCKTON, CA 952023721 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-333-3396 <br /> Mailing Address 640 N EL DORADO ST <br /> STOCKTON, CA 952023721 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0014432 10184663 <br /> Facility Name WILD HORSES 4X4 <br /> Location 640 N EL DORADO ST <br /> STOCKTON, CA 952023721 <br /> Phone 209-943-0991 x0 <br /> Mailing Address 640 N EL DORADO ST <br /> STOCKTON, CA 952023721 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 13906004 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 AR0024512 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name JIM CREEL (Circle One) <br /> Account Balance as of 1/29/2014: $0.00 <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 PR0519290 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533011 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 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: Date <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment T/Ke Check Number Rec by <br /> RENS: . `) till tyf- Date / �1 / Account out: Date <br /> COMMENTS: <br /> Abn 2220k,' <br />