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Date run 8/17/2016 10:20:38AI SAN JOIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/17/2016 <br /> Record Seledion Criteria: Facility ID FA0022907 <br /> Make changes/corrections in RED Ink. 7�/ ��` / <br /> INFORMATION CHANGE(date) 1, <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSNIFed Tax ID : <br /> Owner ID OW0020896 New Owner ID <br /> Owner Name jeffrey jarvis <br /> Owner DBA JARVIS KUSTOMS <br /> Owner Address 6763 VICKSBURG PL <br /> STOCKTON, CA 95207 <br /> Home Phone 209-992-7503 <br /> Work/Business Phone 209-992-7503 <br /> Mailing Address wjparts@gmail.com <br /> STOCKTON. CA 95205-8010 <br /> Care of JARVIS, JEFFREY <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022907 10637266 <br /> Facility Name jarvis kustoms <br /> Location 1813 Cherokee Rd <br /> Stockton, CA 95205 <br /> Phone 209-992-7503 x <br /> Mailing Address 6763 Vicksburg PI <br /> Stockton, CA 95207 <br /> care of jeffrey jarvis <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMall: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> D <br /> Contact Name JARVIS, JEFFREY <br /> Title <br /> Day Phone 209-992-7503 AUG 17 2016 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION ENVIRONMENT HEALTH <br /> Account ID AR0042007 PERMIT/SERVICES New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name JARVISiiST S (Circle One) <br /> Account Balance as of 8/17/2016: 0 <br /> (Circle One) <br /> Transfer to Active/lnactve <br /> ProgreMElemenl and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0540069 EE0000015-TIMOTHY ENGLE Active Y N A 0 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agenlofsame,acknowledge that all site,and'or project specific,PHSIEHD 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 /> Federat Laws. <br /> APPLICANT'S SIGNATURE: e!�l 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 <br /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: <br /> r Invoice#: <br /> 00 -jlk <br />