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Date run 8/31/2015 8:48:54Ary SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Papel <br /> Facility Information as of 8131/2015 <br /> Record Selection Criteria: Facility ID FA0009036 <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 OW0007036 Case Number: H00532 New Owner lD <br /> Owner Name COSTAS AUTOMOTIVE MACHINE LLC <br /> Owner DBA COSTA'S AUTOMOTIVE <br /> OwnerAddress 272 BUTTON AVE <br /> MANTECA, CA 95336 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-823-0781 <br /> Mailing Address 272 BUTTON AVE <br /> MANTECA, CA 95336 <br /> Care of COSTA, JAMES &JESSE <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0009036 10182363 <br /> Facility Name COSTAS AUTOMOTIVE <br /> Location 272 BUTTON AVE <br /> MANTECA, CA 95336 <br /> Phone 209-823-6414 x <br /> Mailing Address 272 BUTTON AVE <br /> MANTECA, CA 95336 <br /> Care of Jim Costa <br /> Location Code 04- MANTECA Alt Phone <br /> BOS District 005- ELLIOTT, BOB Fax <br /> APN 20831024 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 AR0016036 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name COSTAS AUTOMOTIVE (Cirole One) <br /> Account Balance as of 8/31/2015: $0.00 <br /> (Circle One) <br /> Transfer to ActiveAnactva <br /> Program/Element and Description Record ID Employee ID and Name Status New Ownafl Delete <br /> 1920-HMBP-Common Materials PRO519338 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PR0613599 EE0009001 -ELENA MANZO Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511324 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO509036 EE0000000-HAZ MAT SJC IDES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO534338 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project speck,PHSrEHD 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 andfor Standards and State endfor <br /> 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 Check Number Received by <br /> EHD Staff: Date_/_/ Account out: Date <br /> COMMENTS: Invoice#: <br />