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Date ran 10/10/2014 4:25:34P SAN JO�JIN COUNTY ENVIRONMENTAL HEAD DEPARTMENT <br /> Run by Report 1151 1 <br /> Facility Information as of 10/10/2014 Pagel <br /> Record Selection Crena: Facility ID FA0016278 <br /> Make changes/corrections in RED Ink. <br /> INFORMATION CHANGE(date) `� •��� �y <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br /> Owner ID OW0002824 New Owner ID <br /> Owner Name BROADBASE INC. <br /> Owner DBA JIFFY LUBE#1478 (HAMMER) <br /> Owner Address 1700 N BROADWAY <br /> WALNUT CREEK, CA 94596 <br /> Home Phone- (2v`�� �� 'L —��Cl0 <br /> Work/Business Phone 916-375-1155 <br /> Mailing Address 1471 SHORE ST <br /> WEST SACRAMENTO, CA 95691 <br /> Care of BROADBASE INC i JIFFY LUBE <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0016278 10185139 <br /> Facility Name JIFFY LUBE#1478 <br /> Location 1648 E HAMMER LN <br /> STOCKTON, CA 95210 <br /> Phone 209-957-873&-x k10-C� gjZC ' <br /> Mailing Address 1471 SHORE ST <br /> WEST SACRAMENTO, CA 95691 <br /> Care of BROADBASE INC <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District Fax <br /> APN 09428014 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 AR0028468 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name JIFFYLUBE#1478 (CirdeOsi <br /> Account Balance as of 10/10/2014: $0.00 <br /> (Girds One) <br /> Transfer to Active/Inectve <br /> Program/Element and Description Record ID Employee ID and Name statue New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0524482 EE0000006-HAZA SAEED Active Y N A I D <br /> 2229-GEN 50<250 TONS PERMIT PRO524254 EE0000005-FATINAH ZAREEF Active Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PRO527167 EE0000005-FATINAH ZAREEF Active,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533756 Inactivr Y N A I D <br /> BILLING and COMP WWCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,aclmowledge that all site,andor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to re,parry idenfified as Ne OWNER on this form. I also certify that all operations will be performed In accordance with all applicable Ordinance Codes andor Standards and Slate andar <br /> Federal Laws G'7` <br /> APPLICANTS SIGNATURE: // 4'i 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 Receivd <br /> REHS: Date / /_ Account out: Date / l� <br /> COMMENTS: <br /> 1•S_a <br />