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Data mn 7/28/2017 2:11:23PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Repent 021 <br /> Run by <br /> Facility Information as of 7/28/2017 Pagel <br /> Record Selection Cmena'. Facility ID FA0009362 <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 OW0007362 Case Number: H03329 New Owner ID <br /> Owner Name JFD RETYRE INC <br /> Owner DBA JFD RETYRE INC <br /> Owner Address 240 N HUNTER ST <br /> STOCKTON, CA 95202 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-466-4393 <br /> Mailing Address PO BOX 778 <br /> STOCKTON, CA 95201 <br /> Care of DONALDSON, JIM <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0009362 10182627 <br /> Facility Name JFD RETYRE INC <br /> Location 240 N HUNTER ST <br /> STOCKTON, CA 95202 <br /> Phone 209-466-4393 x <br /> Mailing Address PO BOX 778 <br /> STOCKTON, CA 95201 <br /> Care of JIM DONALDSON <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 13913002 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016362 �Sk NewAccount ID: <br /> Mail Invoices to AccountMail Invoices to: Owner / Facility / Account <br /> Account Name JFD RETYRE INC p 0 (Circle One) <br /> Account Balance as of 7/28/2017: $1,263.40 67V <br /> (Circle One) <br /> Transfer to Activesnadve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owners Delete <br /> 1920-HMBP-Common Materials PR0519579 EE0009817-ROBERT LOPEZ Active Y N AI D <br /> 2220-SM HW GEN<5 TONS/YR PRO513788 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO511650 EE0000000-HAZ MAT SJC OES Inactive Y N A D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FE PRO509362 EEOOo0000-HAZ MAT SJC OES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0522405 EE0004486-ANGELICA SANDOVAL MARII Active Y N A 0 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0531409 Inactive Y N A 'Ir D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,anti project specific,PHS/EHD hourly charges associatedwith 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 Ordinance Codes andor Standard, <br /> and State andor Federal Laws. <br /> APPLICANTS 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 C eck Number Received by <br /> EHD Staff: Date 7 / - 17 Account out: <br /> COMMENTS' <br /> Invoic�e#: <br /> d �d (/ C/J IDSZDS G�-1' <br /> � <br /> w <br />