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Date run 3/271 P11 2014 a:15:19SAN JO `IN COUNTY ENVIRONMENTAL HEALReport#5021 <br /> DEPARTMENT Pagel <br /> Run by Facility Information as of 3/27/2014 <br /> Record Selection Criteria: Facility ID FA0009218 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) :-t <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0007218 Case Number: H02163 New Owner ID : <br /> Owner Name Si..L P t n rt p I V c[ N •1 <br /> Owner DBA <br /> Owner Address 2461 HOLLY DR <br /> TRACY, CA 95376 <br /> Home Phone Not Specified <br /> Work/Business Phone 209 83§-9164- h 7 ' h x'1'2 <br /> Mailing Address 2461 HOLLY DR <br /> TRACY, CA 953762128 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0009218 10,182,523 <br /> Facility Name jlMG A61TGMOTIVE VVI 67 q Ca 9fP <br /> Location 2461 HOLLY DR <br /> TRACY, CA 953762120 �� <br /> Phone 209•$35.1148— - <br /> Mailing Address 2461 HOLLY DR <br /> TRACY, CA 953762128 <br /> Care of <br /> Location Code It Phone <br /> BOIS District 005 - ELLIOTT, BOB Fax <br /> APN 21452017 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 AR0016218 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name DIMS AUTOMOTIVE (arae One) <br /> Account Balance as of 3/27/2014: $0.00 <br /> (Circle One) <br /> Transfers, Actwe/InacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO519471 EE0002474-MICHAEL PARISSI Inactive Y N I D <br /> 2220-SM HW GEN<5 TONS/YR PR0513707 EE0002646-THUY TRAN Inactive Y N I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511506 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO509218 EE0000000-HAZ MAT SJC OES Inactive Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531852 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,aam owledge that all site,andor protect specific,PHSEHD 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 ander Standards and State ander <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 NumberRecei y <br /> REHS: 1�1/� ,Date <br /> � r / .�-�/ Account out: Date <br /> COMMENTS: C Vim..*.— A <br />