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Date run 10/22/2018 12:24:51F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 10/22/2018 Record Selection Criteria: Facility ID FA0020058 OWNER FILE INFORMATION Number of facilities for this owner: 1 Owner ID OW0016463 Owner Name Ceja Gerardo Owner DBA CENTRAL VALLEY COLLISION INC 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. APN TRACY, CA 95376 Care of CEJA, GERARDO FACILITY FILE INFORMATION Facility ID / CERS ID FA0020058 10187495 tjtL 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 BOIS District 005 - ELLIOTT, BOB APN 25024001 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name CEJA, BEATRIZ Title VICE-PRESIDENT Day Phone 209-992-7224 Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail : Account ID AR0035753 Mail Invoices to Account Mail Invoices to: Account Name Beatriz Ceja Account Balance as of 10/22/2018: $426.00 New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Active/lnactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1920 - HMBP-Common Materials PR0539201 EE0000009 - NICHOLAS LOEHRER Active Y N A I D 2220 - SM HW GEN <5 TONS/YR PR0531141 EE0009818 - LYDIA BAKER Active Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0534377 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: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS: /^ Date ' $25.00 = Amount Paid Date Amount Paid Date Received by 7— _ Date / / Account out: Date / T Invoice #: