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Date con 12/27/2016 3:37:34F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 12/27/2016 Pagel <br /> Record Selection Criteria: Facility ID FA0005880 <br /> Make changes/corrections in RED ink. 1 L ct <br /> INFORMATION CHANGE(date) Y <br /> ce <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0004681 Case Number. H10064 New Owner ID ^ <br /> Owner Name _ �S L,�IT LI)rt — C . <br /> Owner DBA } _ <br /> OwnerAddress 601 S VENTURA ,4�%V IL <br /> STOCKTON, CA 0203 <br /> Home Phone Not Specified <br /> Work/Business Phone T'9-7747¢8'&--- <br /> Mailing Address 4+9 � - <br /> Care of PS BAJWA Inc. <br /> FACILITY FILE INFORMATION Office(209)467.1195 <br /> Facility ID/CERS ID FA0005880 10181967 CELL(2097470-6062 <br /> Facility Name 601 5 VENTURA AVE <br /> Location 601 S VENTURAAVE STOCKTON, CA 95203 <br /> STOCKTON, CA 95203 Paul Bajwa <br /> Phone 209-469-0810 X OWNER <br /> Psbajwa@livecom— <br /> Mailing Address pe-g�.g�g / <br /> Care of Jp,V46R-GqRC4A <br /> Location Code 01 -STOCKTON Alt Phone - <br /> BOB District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 14509001 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 AR0006743 New Account ID: <br /> Maillnvoicesto mer A— ail Invoices to: Owner / Facility / Account <br /> Account Name � ,5 (Circle one) <br /> Account Balance as of 12/27/2016: $0.00 <br /> (Circle One) <br /> Programleement and Description Recortl ID Employee ID and Neme Status Transfer to ActwOnaelve <br /> New Owner? Delete <br /> 1920-HMBP-Common Materials PR0520974 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO517607 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PRO603560 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO517611 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO524627 EE0000060-JENNIFER FRASE Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO531781 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andtor project spec,PHS/EHD houdy charges associated with this facility <br /> or activity will be billed b the party identified as the OWNER on this form. 1 also cenJy Nat all operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and state andor <br /> Federal laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Typ Check Number Received by <br /> EHD Staff: L. Date ! Z l Y It Account out: Date / / // <br /> COMMENTS: <br /> Invoice#: <br />