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Date run 8/21/2015 8:10:16AN SAN J( UIN COUNTY ENVIRONMENTAL HE) H DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 8/21/2015 <br />Record Selection Criteria: Facility ID FA0015955 <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 <br />Owner ID <br />OW0012880 <br />Owner Name <br />BORGES AUTO SERVICE <br />Owner DBA <br />TRACY, CA 95376 <br />Owner Address <br />850 N MACARTHUR DR <br />Mailing Address <br />TRACY, CA 95376 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-835-7935 <br />Mailing Address <br />850 N MACARTHUR DR <br />BOS District <br />TRACY, CA 95376 <br />Care of <br />BORGES AUTO SERVICE <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0015955 10185061 <br />Facility Name <br />BORGES AUTO SERVICE <br />Location <br />850 N MACARTHUR DR <br />1921 - HMBP-Reqular-Primary Location PR0539039 EE0002474 - MICHAEL PARISSI <br />TRACY, CA 95376 <br />Phone <br />209-835-7935 x <br />Mailing Address <br />850 N MACARTHUR DR <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0532270 <br />TRACY, CA 95376 <br />Care of <br />BORGES AUTO SERVICE <br />Location Code <br />01 - STOCKTON <br />BOS District <br />APN <br />25025010 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0027825 <br />Mail Invoices to Facility <br />Account Name BORGES AUTO SERVICE <br />Account Balance as of 8/21/2015: $0.00 <br />SSN/ Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name <br />Status New Owner? Delete <br />1921 - HMBP-Reqular-Primary Location PR0539039 EE0002474 - MICHAEL PARISSI <br />Active Y N A 0 D <br />2220 - SM HW GEN <5 TONS/YR PR0524266 EE0002646 - THUY TRAIN <br />Active Y N A I D <br />4740 - WASTE TIRE SITE - EXEMPT PR0523652 EE0009000 - HARPRIT MATTU <br />Active Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0532270 <br />Inactive Y N A I D <br />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 <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 and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />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 N ber Received by <br />EHD Staff: _ Date / u / IS Account out: Date <br />COMMENTS: ' <br />Invoice #: <br />