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Date run 8/19/2015 8:32:41AN SAN JC UIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 8/19/2015 <br />Record Selection Criteria: Facility ID FA0016164 <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 <br />Owner ID <br />OW0013058 <br />Owner Name <br />BOK, WADE A <br />Owner DBA <br />TRACY POWER EQUIPMENT <br />Owner Address <br />622 ALMONDCREST ST <br />Payment Ty Check <br />OAKDALE, CA 95361 <br />Home Phone <br />209-833-1000 <br />Work/Business Phone <br />209-833-1000 <br />Mailing Address <br />23901 S CHRISMAN RD <br />TRACY, CA 95304-8022 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0016164 10185089 <br />Facility Name <br />TRACY POWER EQUIPMENT <br />Location <br />7575 CARMELO AVE <br />TRACY, CA 95304 <br />Phone <br />209-833-1000 x <br />Mailing Address <br />23901 S. CHRISMAN RD <br />TRACY, CA 95304-8022 <br />Care of <br />BOK, WADE A <br />Location Code <br />99 - UNINCORPORATED A <br />Bos District <br />005 - ELLIOTT, BOB <br />APN <br />25014013 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0028251 <br />Mail Invoices to Facility <br />Account Name TRACY POWER EQUIPMENT <br />Account Balance as of 8/19/2015: $0.00 <br />1 SSN/Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Reqular-Primary Location PR0539041 EE0002474 - MICHAEL PARISSI Active Y N A0 D <br />2220 - SM HW GEN <5 TONS/YR PR0524047 EE0002646 - THUY TRAN Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0531514 Inactive 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 facility <br />or activity will be billed to the party identified as the OWNER on this form. 1 also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date ! /. <br />Program Records to be TRANSFERED: <br />* $25.00 = Amount Paid <br />Date <br />Water System to be TRANSFERED: <br />Amount Paid <br />Date <br />Payment Ty Check <br />umber Received by <br />Date <br />EHD Sta �-� <br />Date_Account <br />out: <br />COMMENTS: <br />Invoice #: <br />—&- LoVJ C? �/ Pes <br />�� t,.;-,P6-e-n- <br />