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Date run 3/6/2013 10:24:56AM SAN JC UIN COUNTY ENVIRONMENTAL HEA,,.,I DEPARTMENT Report#5021 <br /> Run by � Pagel <br /> Facility Information as of 3/6/2013 <br /> Record Selection Criteria: Facility ID FA0009138 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) 13 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0007138 Case Number: H01479 New Owner ID <br /> Owner Name MANTECA AUTO PLAZA <br /> Owner DBA MANTECA AUTO PLAZA <br /> Owner Address 1190 S MAIN ST <br /> MANTECA, CA 95336 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-239-7777 <br /> Mailing Address PO BOX 1286 <br /> MANTECA, CA 95336 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009138 <br /> Facility Name MANTECA AUTO PLAZA <br /> Location 1190 S MAIN ST <br /> MANTECA, CA 95336 <br /> Phone 209-239-7777 <br /> Mailing Address PO BOX 1286 <br /> MANTECA, CA 95336 <br /> Care of <br /> Location Code 04 - MANTECA Alt Phone <br /> BOS District 005 -ORNELLAS, LEROY Fax <br /> APN 22105023 �J� �7/ EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> f <br /> Account ID AR0016138 G1( oD New Account ID: <br /> Mail Invoices to Facility ��JJ /� Mail lnvoicesto: Owner / Facility / Account <br /> Account Name MANTECA A O PLAZA Q /�� (Circle one) <br /> Account Balance as of 3/6/2013: $ 00 <br /> �)iii / b'r. _/tC� (Circle One) <br /> U'l?✓D�/</voO IIII}j � lN Transfer to ActiveJlnacNe <br /> PrograSUEle <br /> 'Pent and Description L,�.V —3S 8D ec Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location 'PRO520gg5 EE0002474-MICHAEL PARISSI Active Y N A D <br /> 2220-SM HW GEN<5 TONS/YR PR0513666 EE0002670-MUNIAPPA NAIDU Active Y N A D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO511426 EEOO00000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0509138 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0528392 EE0002670-MUNIAPPA NAIDU Active,Exempt Y N A 0 D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO522391 EE0007379-AMANDA BOERTIEN Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0532252 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges associated with this facility <br /> or aCfiydy will be billed to the party identified as the OWNER on this form I also cer ify that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and State andor <br /> Federal Laws. <br /> APPLICANT'S 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 Z <br /> RENS: DV7 yam" -t-! t Date / /� Account out: Date / / /.3 <br /> COMMENTS: <br />