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Date run ;2/1 /2016 3:52:55PN SAN J(WIN COUNTY ENVIRONMENTAL HEA DEPARTMENTRun byl- Report 175021 <br /> Facility Information as of 2/11/2Pagel <br /> Record Seliteria: Facility ID FA0011023 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 3 SSN/Fed Tax ID : <br /> Owner ID OW0007393 Case Number: H03711 New Owner ID <br /> Owner Name MORGANSON, DAVE <br /> Owner DBA <br /> Owner Address 3812 MONDRIAN DR <br /> MODESTO, CA 953562448 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-678-0039 <br /> Mailing Address PO BOX 6463 <br /> STOCKTON, CA 95206 <br /> Care of COSLETT, RICK <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0011023 10184043 <br /> Facility Name INTERSTATE TRUCK CTR-COLLISION DI <br /> Location 641 S Harrison St <br /> Stockton, CA 95203 <br /> Phone 209467-3561 x n n <br /> Mailing Address PO BOX 6463 <br /> STOCKTON, CA 95206 <br /> Care of COSLETT, RICK <br /> Location Code Alt Phone <br /> BOIS District Fax <br /> APN 14704047 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 AR0018023 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name INTERSTATE TRUCK CTR -COLLISION DI (Circle one) <br /> Account Balance as of 2/11/2016: $248.00 <br /> (Circle One) <br /> Transfer to Active/Inacwe <br /> PrograMElemenl and DescriptionRecord ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0520616 EE0009817-ROBERT LOPEZ Inactive Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PR0514497 EE0001421 -STACY RIVERA Active Y N A (� D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513311 EE0000000-HAZ MAT SJC IDES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO511023 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO528799 EE0001421 -STACY RIVERA Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534024 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and'or project specific,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form I also caddy that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State and(or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type It k Number Received by <br /> EHD Staff: ate / / Account out: Date <br /> COMMENTS: / vO <br /> �IV/ 1�.r.— �,, Invoice#: <br />