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Date run 2/1/2013 11:30:45AM SAN JO�JIN COUNTY ENVIRONMENTAL I1EAI..I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/1/2013 <br /> Record Selection Criteria: Facility ID FA0010470 <br /> Make changes/corrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008470 Case Number: H08165 New Owner to <br /> Owner Name POLIMENO, JOHN <br /> Owner DBA ELEGANT SURFACES <br /> Owner Address 551 CARNEGIE ST <br /> MANTECA, CA 95337 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-823-9388 <br /> Mailing Address 551 CARNEGIE ST <br /> MANTECA, CA 95337 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010470 <br /> Facility Name ELEGANT SURFACES <br /> Location 551 CARNEGIE ST <br /> MANTECA, CA 95337 <br /> Phone 209-823-9388 <br /> Mailing Address 551 CARNEGIE ST <br /> MANTECA, CA 95337 <br /> Care of <br /> Location Code 04 -MANTECA Alt Phone <br /> BOS District 005-ORNELLAS, LEROY Fax <br /> APN 22119064 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 AR0017470 New Account ID: <br /> Maillnvoicesto OwnerMail Invoices to: Owner / Facility / Account <br /> Account Name POLIMENO' <br /> N (Circle One) <br /> Account Balance as of 2/1/2013: $6 kR <br /> (Circle One) <br /> Transfer to Active4nactve <br /> m/Elemnt and Description ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO520337 EE0002474-MICHAEL PARISSI Active Y N A rA)� D <br /> SM HW GEN<5 TONSNR PR0514339 EE0002670-MUNIAPPA NAIDU Active Y N A (T D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOtPR0512758 EE00o0000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0510470 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0531286 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD 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 andor Standards and State andor <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 Recely db <br /> RENS:* 7 Date / I Account out: rpZD,atta <br /> COMMENTS:I )3 _' Cly /1'✓�M� / R.'YI�'Q/11 L92L- /I' ..[.q/��C-9?�Rx'"` /�y4'"IQ� t"� I.J <br /> — av{t-o -�cC'Cid-7fi�C'ISe.r� H.0 ��a�p,.�-✓�0-e tt� vim `" �""""""' `�"'1 <br />