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Data run 5/3/2017 9:41:42AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 85021 <br /> Run by Paget <br /> Facility Information as of 5/3/2017 <br /> Record Selection Criteria: Facility ID FA0009631 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0007631 Case Number: H05020 New Owner ID <br /> Owner Name JARVIS, JEFFREY <br /> Owner DBA JARVIS KUSTOMS INC <br /> Owner Address 6763 VICKSBURG PL <br /> STOCKTON, CA 95207 <br /> Home Phone 209-992-7503 <br /> Work/Business Phone 209-992-7503 <br /> Mailing Address 6763 VICKSBURG PL <br /> STOCKTON, CA 95207 <br /> Care of JARVIS, JEFFREY <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0009631 10689295 <br /> Facility Name JARVIS KUSTOMS <br /> Location 845 S COMMERCE St <br /> STOCKTON, CA 95206 <br /> Phone 209-992-7503 x <br /> Mailing Address 6763 VICKSBURG PL <br /> STOCKTON, CA 95207 <br /> Care of JARVIS, JEFFREY <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name JARVIS, JEFFREY <br /> Title MANAGER <br /> Day Phone 209-992-7503 <br /> Night Phone 209-992-7503 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016631 New Account ID: <br /> Mail Invoices to Account (/ Mail Invoices to: Owner / Facility / Account <br /> Account Name JARVIS KUST MS hf`y\ /I (Circle One) <br /> Account Balance as of 5/3/2017: $824 T " J �\(}��\1 <br /> N (Circle One) <br /> �/ Transfer to Aclive/Inaclve <br /> Progra"Element and DescriptionRecord Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Loca on PRO519784 EE0009817-ROBERT LOPEZ Active Y N AD <br /> 2220-SM HW GEN<5 TONS/YR PR0538423 EE0000026-CESAR RUVALCABA Active Y N A D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO511919 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO509631 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534037 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent of same,acknowledge that all site,anrYor project specific,PHSEHD hourly charges associated with this facility <br /> or activity will he 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 Stale anclor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: C� %!i�—�� Date S ! J / / 7 <br /> Program Records to be TRAN FERED: *$25.00= Amount Paid Date / ! <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type�eck Number Received by <br /> EHD Staff. Date Account out: Date 7J / /7 <br /> COMMENTS: <br /> Invoice#: <br /> /VO /Owgf✓ Cif 7-y G,J.�:f� QS G f / <br />