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to run " 4/10/2014 10:44:21AI SAN JO. .N COUNTY ENVIRONMENTAL HEAL )EPARTMENT Report#5021 Run by It Pagel Facidy Information as of 4/10/2014 Record Selection Criteria: Facility ID FA0010816 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID Owner ID OW0008816 Case Number: H08804 New Owner ID Owner Name JESSUP, JOHN I D Owner DBA EE0009488 - JEFFREY WONG Active Y N A Owner Address 20861 E WALNUT DR EE0000000 - HAZ MAT SJC OES Inactive Y N A LINDEN, CA 95236 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PRO510816 Home Phone 209-467-4669 I D Work/Business Phone 209-351-2311 A Mailing Address 20861 E WALNUT DR 93 561— A Federal Laws. LINDEN, CA 93236 -— Care of APPLICANT'S SIGNATURE: Date ! / FACILITY FILE INFORMATION Program Records to be TRANSFERED: ' $25.00 = Facility ID / CERS ID FA0010816 Facility Name JESSUP'S MOTORCYCLE REPAIR Location 2383 N WILSON WAY Received by Date STOCKTON, CA 95205 REHS: Date / Phone 209-467-4669 Mailing Address 20861 E WALNUT DR 3 4J ai LINDEN, CA 93236 1V5 Care of Location Code 99 - UNINCORPORATED P Alt Phone BOS District 002 - RUHSTALLER, LARRY Fax APN 11707050 EMail: EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name JOHN JESSUP Title PRESIDENT Day Phone 209-467-4669 Night Phone 209-351-2311 ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0017816 New Account ID: Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account Account Name JESSUP'S MOTORCYCLE REPAIR (Circle One) Account Balance as of 4/10/2014: $709.00 (Circle One) Transfer to Active/lnactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1921 - HMBP-Regular-Primary Location PR0520504 EE0006044 - LOWELL ALLEN Inactive Y N A I D 2220 - SM HW GEN <5 TONS/YR PR0514426 EE0009488 - JEFFREY WONG Active Y N A I D 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513104 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PRO510816 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 3122 - STORMWATER INSPECTION - AUTO SHOP PR0522991 EE0009488 - JEFFREY WONG Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date ! / Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received by Date REHS: Date / / Account out: 1� COMMENTS: r