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Data run 8/1712016 10:01:28AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by ' Pagel <br /> Facility Information as of 8/17/2016 <br /> Record Selegion Chill Facility ID FA0009631 <br /> Make changesicorrections in RED ink. 7 �^ <br /> INFORMATION CHANGE(date) o� <br /> <br /> <br /> Owner ID OW0007631 Case Number: H05020 New ow r <br /> Owner Name Jarvis Mobile Repair ji P✓!a 43 aIn ,Tree <br /> Owner DBA JI rs 4N% <br /> ii <br /> Owner Address 2825 PELLISSIER PL _ <br /> 5763 1 Ss <br /> CITY OF INDUSTRY, CA 90601 S'Fo mow C/F S2a7 <br /> Home Phone Not Specified <br /> Work/Business Phone 888-359-3999 'CJ4— $'0 <br /> Mailing Address 2825 pillisier pl Co 7Q U:c1cs ba eq PC- <br /> City of Industry, CA 90601 Sfo fo-V C'4 <br /> Care of BRAMALL, CHRIS Jill aPet.S- <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0009631 10689295 <br /> Facility Name Jarvis Kustoms <br /> Location 845 S COMMERCE ST <br /> STOCKTON, CA 95206 <br /> Phone 209-992-7503 x <br /> Mailing Address 2825 Pellisier PI C7Wiii ktCqL <br /> City of Industry, CA 90601 li�*»o fgvu li TS20-7 <br /> Care of Christopher Bramall ai jqvi <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN EMail <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name LOUIS DAWANG JEF' Jai i's <br /> Title MANAGER ppyMENT a,,,,i <br /> Day Phone 209-948-4410 RECEIVED „ i - - 7SO3 <br /> Night Phone <br /> AUG 17 <br /> 2016 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016631 SAN JOAQUIN COUNTY New Account ID: <br /> Mail Invoices to Account ENVIROMENTAL <br /> HEALTH DEPARTMENT Mail Invoices to: Owne / Facility / Account <br /> Account Name Jarvis KUstomS (Circe One) <br /> Account Balance as of 8/17/2016: $0.00 <br /> (Circle One) <br /> Transfer to Activa/Inal <br /> Program/Element and Descripbon Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO519784 EE0009817-ROBERT LOPEZ Active NI D <br /> 2220-SM HW GEN<5 TONS/YR PR0538423 EE9999998-ONE VACANTI Active Y N gA I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO511919 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO509631 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534037 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andior project speck,PHS/EHD hourly charges associated with this facility <br /> or aCivity will be billed to the party identified as the OWNER on this form. Ialso barfly that all operations will be performed in accordance with all applicable Ordinance Codes angor Standards and State andor <br /> Fecteral Laws. <br /> APPLICANTS SIGNATURE: Date _d 17 / /6 <br /> Program Records to be TR$NSFERE '$25.00= Amount Paid �` •�Date <br /> Water Systemic be TRAN FE D: Amount Pal yyi Date /�Z�2 <br /> Paymen ype heck Number Received <br /> Date /7/ Account out: Date /Z:2-116 <br /> COMMENTS: Invoice#: 24-Z /'I L 10 <br />