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Date run 8/12/2010 2:44:44PN SAN Jt `?UIN COUNTY ENVIRONMENTAL HES" �H DEPARTVIENT Report#5021 <br /> Run by I Pagel <br /> Facility Information as of 8/12/2u.0 <br /> Record Selection Criteria: Far°Pty ID FA0003750 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0002787 New Owner ID <br /> Owner Name C KELLEY TRUCKING INC <br /> Owner DBA C KELLEY TRUCKING <br /> Owner Address 4969 E WATERLOO RD <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-931-3035 <br /> Mailing Address 4969 E WATERLOO RD <br /> STOCKTON, CA 95205 <br /> Care of C KELLEY TRUCKING INC <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0003750 <br /> Facility Name C KELLEY TRUCKING <br /> Location 4969 E WATERLOO RD <br /> STOCKTON, CA 95205 <br /> Phone 209-931-3035 <br /> Mailing Address 4969 E WATERLOO RD <br /> STOCKTON, CA 95205 <br /> Care of C KELLEY TRUCKING INC <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN EMail : <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone 209-931-3035 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003329 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name C KELLEY TRUCKING (Circle One) <br /> Account Balance as of 8/12/2010: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2221 -USED OIL ONLY-<5 TONS/YR PR0513731 EE0004636-GARRETT BACKUS Active Y N A D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO511549 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0231754 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARtPR0507437 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARFIR0509261 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATI\PR0528342 EE0004636-GARRETT BACKUS Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0534797 Active Y N A I D <br /> 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 <br /> 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date_�/ if Account out: Date <br /> COMMENTS: <br /> /4 Cv 2^t53 <br /> /�� r`. <br /> \\eh-env\envision\reports\5021.rpt <br /> / / tQ 2g3�_ <br />