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Date run 9/21/2015 11:28:42AI SAN JUIN COUNTY ENVIRONMENTAL HEAW DEPARTMENT Report*5021 <br /> Run by Pagel <br /> Facility Information as of 9/21/2015 <br /> Record Selection Criteria: Facility ID FA0016213 <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 OW0013109 New Owner ID <br /> Owner Name ROBERT BUMSTEAD <br /> Owner DBA TRUCK LUBRICATION COMPANY <br /> Owner Address 143 S PIXLEY ST <br /> ORANGE, CA 92868 <br /> Home Phone Not Specified <br /> Work/Business Phone 714-997-7730 <br /> Mailing Address 143 S PIXLEY ST <br /> ORANGE, CA 92868 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0016213 10185125 <br /> Facility Name TRUCK LUBRICATION COMPANY <br /> Location 523 W LARCH RD STE A <br /> TRACY, CA 95304 <br /> Phone 209-833-3409 x0 <br /> Mailing Address 523 W LARCH RD STE A <br /> TRACY, CA 95304 <br /> care of Lonnie Gorman <br /> Location Code Alt Phone <br /> BOS District 003- BESTOLARIDES, STEVE Fax <br /> APN 21220005 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 AR0028336 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name TRUCK LUBRICATION COMPANY (Circle One) <br /> Account Balance as of 9/21/2015: $0.00 <br /> (Circle One) <br /> Transferto Activa9nal <br /> PrograrmElemenl and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO524122 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2221 -USED OIL ONLY-<5 TONS/YR PR0535902 EE0002646-THUY TRAN Active Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PR0535903 EE0002646-THUY TRAN Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533907 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor 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 andlor Standards and State andfor <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 I / Account out: Date <br /> COMMENTS: Invoice#: <br />