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[Date nud 5/6/2010 9:02:16AM SAN J( 1UIN COUNTY ENVIRONMENTAL HEP` 'H DEPARTMENT Report#5021 <br /> Run by <br /> Facility tilformation as of 5/6/21"6 Pagel <br /> Record Selection Criteria: Facility ID FA0009869 <br /> Make changesicotrections in RED ink. <br /> INFORMATION CHANGE(date) _(k� <br /> �--- OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0007869 Case Number: H05686 New Owner ID <br /> Owner Name HENRIQUES, ED/WAGONER, BRIAN <br /> Owner DBA JM EQUIPMENT CO INC <br /> Owner Address 1245 W CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Home Phone 209-052-7654 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1245 W CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009869 <br /> Facility Name JM EQUIPMENT CO INC <br /> Location 1245 W CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Phone 209-466-0707 <br /> Mailing Address 1245 W CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Care of HENRIQUES, ED/WAGONER, BRIAN <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 163230345 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name EDWARD HENRIQUES <br /> Tide PRESIDENT <br /> Day Phone 209-522-3271 <br /> Night Phone 209-522-3271 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016869 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name JM EQUIPMENT CO INC (Gmloone) <br /> Account Balance as of 5/6/2010: $0.00 <br /> (circle One) <br /> Transfer to ActivelinacNe <br /> Program/Element and Description Record 10 Employee ID and Name Stales New OwneO Delete <br /> 0)SM HW GEN<5 TONSNR PRO514071 EE0008317-RAYMOND VON FLUE Active Y N A D <br /> -HAZ MAT BUSiN PLAN AUTHORIZATIOIPRO512157 EE0000000-HAZ MAT SJC OES Inactive Y N A D <br /> 2244-PACT TRANSFER RECORD-IDES PRO520938 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399'- ROGRAM FAC STATE SURCHARPRO509869 EE0000000-HAZ MAT SJC OES Inactive Y N A -�Q D <br /> 2 -AST EXEMPT FAC <1,320 GAL PR0531133 EE0008317-RAYMOND VON FLUE Acfive,Exempt Y N A Qin D <br /> 4%40-WASTE TIRE SITE-EXEMPT PR0526480 EE0004680-NATALIA SUBBOTNIKO'Active Y N A o�(� D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PRO533405 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned wnrer.operator or agent of same,acknowledge that all site,and/or Project specific.PHS/EHD hourly charges associated with this <br /> faciity or activity will be bipart m the party dentin as the OWNERonthis form. I also ce/rti <br /> ify that <br /> all operaboro will be <br /> Pe ed in accordance with all applicable Orel ce Cortes andlor Standards and <br /> Slate 0,dlor Federal Lawa.t L 1 ` 2 2 Y l! F `9 `-' I / 1_/y] Im " " Q u <br /> Q1�� I n nLr�i//��A�-� r yW� <br /> APPLICANTS SIGNATURE: r`1 I '� "'q 1� J� -,5 Date / / <br /> Program Records to be TRANSFERED: `$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: `$372.00= Amount Paid D to <br /> Payment Check Number Ra— <br /> z <br /> REHS: Date / / Account out: Date / /� <br /> COMMENTS�\T� r��� <br /> Ileh-en,Aenvisionlreports\5021.rpt /YW/ -"IY ILS] r <br />