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Date run 3/16/2016 1:35:58PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 3/16/2016 Record Selection Criteria: Facility ID FA0010020 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN /Fed Tax ID Owner ID OW0008020 Case Number: H06264 New Owner ID Owner Name T{ Owner DBAn�i ivT-K)c na o jaN 4R_E pqg Ly-NIS i- Owner Address 1600 W LINNE RD TRACY, CA 953778023 Home Phone Not Specified Work/Business Phone _ _ Zo 5'x''3 b-t- bo Mailing Address 1600 W LINNE RD TRACY, CA 95377-9544 Care of �.— FACILITY FILE INFORMATION Facility ID / CERS ID FA0010020 10183127 Facility Name Location 1600 W LINNE RD TRACY, CA 95377-8023 Phone 209-836-6460 x0 Mailing Address 1600 W LINNE RD TRACY, CA 95377-9544 Care of aw, RL OA-- Location Code 03-TRACY Alt Phone BOS District 005 - ELLIOTT, BOB Fax APN 25311003 EMail: EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0017020 New Account ID: Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account Account Name TED M BOLLS SR (Circle One) Account Balance as of 3/16/2016: $5�J3 �^'L �—- (Circle One) Transferto Active/Inaclve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1921 - HMBP-Regular-Primary Location PR0520028 EE0000010 - PETER LOMBARDI Active Y N A I D 2220 - SM HW GEN <5 TONS/YR PR0539455 EE0001459 -VICKI MCCARTNEY Active Y N A I D 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512308 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510020 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2840 - AST EXEMPT FAC < 1,320 GAL PRO528307 EE0002646 - THUY TRAN Inactive Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0532407 Inactive Y N A I D 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 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 and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: ` $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Receivedy EHD Staff: Date. / Account out: Date COMMENTS: i7 r� � Invoice #: / w Z=7tl