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Date run 2/18/2015 1:27:40Pf\ SAN J UIN COUNTY ENVIRONMENTAL HEI DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/18/2015 <br />Record Selection Criteria: Facility ID FA0017245 <br />OWNER FILE INFORMATION Number of facilities for this owner : 1 <br />Owner ID <br />OW0014086 <br />Owner Name <br />JERRYATKINS <br />Owner DBA <br />JERRYATKINS <br />OwnerAddress <br />12332 E HWY 26 <br />Phone <br />STOCKTON, CA 95215 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-931-3725 <br />Mailing Address <br />12332 E HWY 26 <br />Location Code <br />STOCKTON, CA 95215 <br />Care of <br />PR0530274 <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0017245 10186141 <br />Facility Name <br />JERRYATKINS <br />Location <br />12332 E HWY 26 <br />Program/Element and Description <br />STOCKTON, CA 95215 <br />Phone <br />209-931-3725 x <br />Mailing Address <br />12332 E HWY 26 <br />1958 - HM -Farm Operations <br />STOCKTON, CA 95215 <br />Care of <br />Jerry Atkins <br />Location Code <br />A I D <br />BOS District <br />PR0530274 <br />APN <br />10318007 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />2830 - AST FAC - SPCC EXEMPT <br />Title <br />Day Phone <br />EE0009488 - JEFFREY WONG <br />Night Phone <br />Y N <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0030127 <br />Mail Invoices to Owner <br />Account Name JERRYAT <br />Account Balance as of 2/18/2015: Iff <br />.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) 2-11015 <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />4 PS A Eli rCb"°-)-t-, eaz- <br />(Circle One) <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 T pe Check Number Received b <br />REHS: � V -1J Date 2 /3/ Account out: Date <br />COMMENTS: <br />F1 eA� _r Ill p-7< 2 01 v . <br />S P616q� Lq TQ Ir At Ic " , �� t1liel <br />Transfer to <br />Active/Inactve <br />Program/Element and Description <br />Record ID <br />Employee ID and Name <br />Status <br />New Owner? <br />Delete <br />1958 - HM -Farm Operations <br />PR0525430 <br />EE0000006 - HAZA SAEED <br />Active <br />Y N <br />A I D <br />2220 - SM HW GEN <5 TONS/YR <br />PR0530274 <br />EE0009488 - JEFFREY WONG <br />Active <br />Y N <br />A I D <br />2830 - AST FAC - SPCC EXEMPT <br />PR0530273 <br />EE0009488 - JEFFREY WONG <br />Active <br />Y N <br />AI D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG <br />PR0531958 <br />Inactive <br />Y N <br />A 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 <br />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 T pe Check Number Received b <br />REHS: � V -1J Date 2 /3/ Account out: Date <br />COMMENTS: <br />F1 eA� _r Ill p-7< 2 01 v . <br />S P616q� Lq TQ Ir At Ic " , �� t1liel <br />