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Date run 8/18/2015 8A&41Ah SAN J(UIN COUNTY ENVIRONMENTAL HEA H DEPARTMENT Report 45021 Run by g Pa e1 Facility Information as of 8/18/2015 Record Selection Criteria: Facility ID FA0020058 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) OWNER FILE INFORMATION Number of facilities for this owner: 1 Owner ID OW0016463 Owner Name Ceja Gerardo Owner DBA Owner Address 1426 POPPY HILLS LN TRACY, CA 95377 Home Phone 209-814-6047 Work/Business Phone 209-830-0561 Mailing Address 24580 S MacArthur Dr, TRACY, CA 95376 Care of CENTRAL VALLEY COLLISION CENTR FACILITY FILE INFORMATION Facility ID / CERS ID FA0020058 10187495 Facility Name CENTRAL VALLEY COLLISION CENTER Location 24580 S MACARTHUR DR TRACY, CA 95376 Phone 209-830-0561 x Mailing Address 24580 S MACARTHUR DR TRACY, CA 95376 Care of Gerardo Ceja Location Code 99 - UNINCORPORATED P BOS District 005 - ELLIOTT, BOB APN 25024001 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0035753 Mail Invoices to Facility Account Name CENTRAL VALLEY COLLISION CENTER Account Balance as of 8/18/2015: $0.00 SSN /Fed Tax ID New Owner ID Alt Phone Fax W EMail : New Account ID: Mail Invoices to: Owner 1 Facility 1 Account (Circle One) (Circle One) Transfer to Activefinacive Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1920 - HMBP-Common Materials PRO539201 EE0002474 - MICHAEL PARISSI Active Y N A I D 2220 - SM HW GEN <5 TONS/YR PRO531141 EE0002646 - THUY TRAN Active Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO534377 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 idenlired 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 and/or Federal Laws. APPLICANTS SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS: Date I 1 " $25.00 = Amount Paid Date 1 1_ Amount Paid Date ! / Date I I. Received by Account out: Date I 1 Invoice #: