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Dalerun 3/19/2015 3:42:10Pn SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 3/19/2015 Paget <br /> Record Selector,Criteria: Facility ID FA0020071 <br /> Make changes/corrections in RED ink <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0016479 New Owner ID <br /> Owner Name COBB, RYAN P <br /> Owner DBA CLUTCHES N MORE INC <br /> Owner Address 1057 SPRINGOAK WAY <br /> STOCKTON, CA 95209 <br /> Home Phone 209-478-8331 <br /> Work/Business Phone 209-478-8331 <br /> Mailing Address 1057 SPRINGOAK WAY <br /> STOCKTON, CA 95209 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0020071 10187499 <br /> Facility Name CLUTCHES N MORE _ <br /> Location 4629 N WEST LN <br /> STOCKTON, CA 95210 —' <br /> Phone 209-478-8331 x <br /> Mailing Address 1057 SPRINGOAK WAY <br /> STOCKTON, CA 95209 <br /> Care of COBB, RYAN P <br /> Location Cade 01 -STOCKTON Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 10437014 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 AR0035795 New Account ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name CLUTCHES N MORE (ardeOne) <br /> Account Balance as of 3/19/2015: $0.00 <br /> (Circe One) <br /> Transferlo AcbveAreci <br /> PmgraMElement and Description Reoord ID Employee to antl Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0539195 EE0000006-HAZA SAEED Active Y N A D <br /> 2220-SM HW GEN<5 TONSNR PR0531158 EE0000005-FATINAH ZAREEF Active Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534056 Inactive Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent or same,acknowledge that all site,anrYor project specific,PHSEHD hourly charges associated with this facility <br /> or adivity,will ba billed to the party identified as me OWNER on this faun I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State ander <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 Ty Check Number Received by <br /> REHS: Date_/ rQ_>/ Accountout: 11A Date <br /> COMMENTS: <br /> I—C (fin vat5r �t on �si:m �ju.St SSS l L KDCO`Gtur� h(LS CI�W>�vcl u Q <br /> ulu� OSS T <br />