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L-ri Date run `/17/2013 9:57:07AN SAN J( UIN COUNTY ENVIRONMENTAL HE/ I DEPARTMENT Report#5021 Run by i Fat_-ility Infbrmation as of 6/17/2013 Pagel Record Selection Criteria: Facility ID FA0010816 OWNER FILE INFORMATION Owner ID OW0008816 Case Number: H08804 Owner Name JESSUP, JOHN Owner DBA Delete Owner Address 20861 E WALNUT DR EE0006044 - LOWELL ALLEN LINDEN, CA 95236 Home Phone 209-467-4669 Work/Business Phone 209-351-2311 Mailing Address 20861 E WALNUT DR Active LINDEN, CA 95236 Care of I D FACILITY FILE INFORMATION Facility ID / CERS ID FA0010816 Facility Name JESSUP'S MOTORCYCLE REPAIR Location 2383 N WILSON WAY STOCKTON, CA 95205 Phone 209-467-4669 Mailing Address 20861 E WALNUT DR LINDEN, CA 95236 Care of Location Code 99 - UNINCORPORATED P BOS District 002 - RUHSTALLER, LARRY APN 11707050 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name JOHN JESSUP Title PRESIDENT Day Phone 209-467-4669 Night Phone 209-351-2311 ACCOUNTS RECEIVABLE FILE INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail : Account ID AR0017816 Mail Invoices to Facility Mail Invoices to: Account Name JESSUP'S MOTORCYCLE REPAIR Account Balance as of 6/17/2013: $461.00 New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1921 - HMBP-Regular-Primary Location PRO520504 EE0006044 - LOWELL ALLEN Active 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 PR0510816 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 and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: " $25.00 = Water System to be TRANSFERED: Payment Type Check Number REHS: Date COMMENTS: n RUQ 3�`3 Amount Paid _ Amount Paid Account out: Date Date Date Received by Date