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Date run 6/7/2013 9:06:42AM SAN JOIN COUNTY ENVIRONMENTAL IIEA*DEPARTMENT Report#5021 <br /> Run by - Pagel <br /> Facility Information as of 6/7/2013 <br /> Record Selection Criteria: Facility ID FA0010067 <br /> Make changesicorrections in RED ink. C' <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008973 Case Number: H09071 New Owner to <br /> Owner Name FOWLER, DON W <br /> Owner DBA BROADBASE INC dba JIFFY LUBE <br /> Owner Address 1471 SHORE ST <br /> WEST SACRAMENTO, CA 95691 <br /> Home Phone 916-375-1155 <br /> Work/Business Phone 209-339-0795 <br /> Mailing Address 1471 SHORE ST <br /> WEST SACRAMENTO, CA 95691 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0010067 10,183,177 <br /> Facility Name JIFFY LUBE#2497 <br /> Location 4715 N WEST LN <br /> STOCKTON, CA 95210 <br /> Phone 209-952-1662 <br /> Mailing Address 1471 SHORE ST <br /> WEST SACRAMENTO, CA 95691 <br /> Care of BROADBASE INC dba JIFFY LUBE <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 10437012 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 AR0017067 New Account ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name JIFFY LUBE#2497 (CimleOne) <br /> Account Balance as of 6/7/2013: $0.00 <br /> (Circle One) <br /> Transfer to ActivellnacNe <br /> Progra"Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO521063 EE0006044-LOWELL ALLEN Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512356 EEOOOOOOO-HAZ MAT SJC OES Inactive Y N A I D <br /> 2228-GEN 25<50 TONS PERMIT PRO514152 EE0004636-GARRETT BACKUS Active Y N A I D <br /> 2332-EXEMPT TANK FACILITY PRO528061 EE0004636-GARRETT BACKUS Active,l Y N A4!fC-> D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO510067 EEOOOOOOO-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531485 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor protea specific,PHS/EHD hourly charges associated with this facility <br /> 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 Ordinanoe Codes and'or Standards and State andor <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 Recely <br /> REHS: //:n S Date L� l /� Account out: Date / 13 <br /> COMMENTS: f J- �j�j}2� I g 2 <br /> 6911 <br /> A -Z$3 V:11 � rs�� <br />