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Date run 12/23/2014 8:41:11A SAN JOIN COUNTY ENVIRONMENTAL HEA*DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/23/2014 <br /> Record Selection Criteria: Facility ID FA0010277 <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: 4 SSN/Fed Tax ID <br /> Owner ID OW0007783 New Owner ID <br /> Owner Name BRANNON, J/CUMBERLEGE, C <br /> Owner DBA BRANNON TIRE CORP <br /> Owner Address 3730 N WILSON WAY <br /> STOCKTON, CA 95205 <br /> Home Phone 209-466-1881 <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 1988 <br /> STOCKTON, CA 95201 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0010277 10183393 <br /> Facility Name BRANNON TIRE CORP <br /> Location 3730 N WILSON WAY <br /> STOCKTON, CA 95205 <br /> Phone 209-467-0154 <br /> Mailing Address PO BOX 1988 <br /> STOCKTON, CA 95201 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 13207011 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017277 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name BRANNON TIRE CORP (Circle One) <br /> Account Balance as of 12/23/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/InacNe <br /> Progr unriffement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO520196 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PROB12565 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2227-GEN 5<25 TONS PERMIT PRO523488 EE0009488-JEFFREY WONG Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510277 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 3122-STORMWATER INSPECTION-AUTO SHOP PRO623079 EE0009488-JEFFREY WONG Inactive Y N A I D <br /> 4730-WASTE TIRE HAULER PR0522463 EE0009000-HARPRIT MATTU Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531541 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHS/EHD hourly charges associated with his facility <br /> or activity will be billed to the party identified as the OWNER on this form. Ialso codify that all operations will be Performed in accordance with all applicable Ordinance Codes andeor standards and state ands <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 Check Number Received by <br /> REHS: Date /_/ Account out: Date <br /> COMMENTS: <br />