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Date run 6i26/2013 4:22:09PA SAN JOA, JIN COUNTY ENVIRONMENTAL HEAL ,.>< DEPA4TMENT `! Report #5021 <br />Run by ' <br />Facility Information as of 6/26/2013 <br />Record Selection Criteria: Facility ID FA0010269 <br />OWNER FILE INFORMATION <br />Owner ID OW0008269 Case Number: H07535 <br />Owner Name TORBETT, PAUL M <br />Owner DBA SPEE DEE OIL CHANGE & TUNE-UP <br />Owner Address 471 SAN CARLOS WAY <br />STOCKTON, CA 95207 <br />Home Phone Not Specified <br />Work/Business Phone 760-787-0334 <br />Mailing Address 471 SAN CARLOS WAY <br />STOCKTON, CA 95207 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID/CERS ID FA0010269 10,183,387 <br />Facility Name SPEEDEE OIL CHANGE & TUNE-UP <br />Location 471 SAN CARLOS WAY <br />STOCKTON, CA 95207 <br />Phone 209-472-9272 <br />Mailing Address 471 SAN CARLOS WAY <br />STOCKTON, CA 95207 <br />Care of <br />Location Code 01-STOCKTON <br />Bos District 002 - RUHSTALLER, LARRY <br />APN 08152044 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Account ID AR0017269 <br />NewAccount ID: <br />: <br />Mail Invoices to Facility <br />Mail Invoices to: <br />Owner / <br />Facility <br />/ <br />Account <br />Account Name SPEEDEE OIL CHANGE & TUNE-UP <br />(Circle One) <br />Account Balance as of 6/26/2013: $0.00 <br />(Circle One) <br />Transfer <br />to <br />Active/Inactve <br />ProgranUElement and Description <br />Record ID <br />Employee ID and Name <br />Status <br />New Owner? <br />Delete <br />1921 - HMBP-Regular-Primary Location <br />PRO520249 <br />EE0009817 - ROBERT LOPEZ <br />Active <br />Y <br />N <br />A <br />I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION <br />PRO512557 <br />EE0000000 - HAZ MAT SJC OES <br />Inactive <br />Y <br />N <br />A <br />I D <br />2228 - GEN 25<50 TONS PERMIT <br />PR0514264 <br />EE0004636 - GARRETT BACKUS <br />Active <br />Y <br />N <br />A <br />I D <br />f2'73_j2 = EXEMPT TANK FACILITY <br />PR0528059 <br />EE0004636 - GARRETT BACKUS <br />Active,l <br />Y <br />N <br />A <br />(- I ; D <br />2399 -UNIFIED PROGRAM FAC STATE SURCHARGE F <br />PRO510269 <br />EE0000000 - HAZ MAT SJC OES <br />InactivE <br />Y <br />N <br />A <br />I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG <br />PR0533167 <br />InaCtIVE <br />Y <br />N <br />A <br />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 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 Ordinance Codes andror Standards and State andlor <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: 0,At /c:,L,5 Date Account out: Date /_ <br />COMMENTS: <br />--,73,32 <br />A ekQ z 3 <br />