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Date run 10/28/2015 10:17:59/ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/28/2015 <br /> Record Selection Criteria: Facility ID FA0012470 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID .NY <br /> Owner ID OW0009672 New Owner ID <br /> Owner Name { W4E <br /> Owner DBA ill —kap A l IL PtC 6'LlEtS TQC . <br /> Owner Address 740 N MAIN <br /> MANTECA, CA 95336 <br /> Home Phone Not Specified <br /> Work/Business Phone e68' ZO g3 0� a <br /> Mailing Address 740 N MAIN ST <br /> MANTECA, CA 95336 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0012470 10184283 <br /> Facility Name *%J.FF-L-ER-S-&-fAeRE— IY7,4AJ-7W4 t' &2&S Sry 63 <br /> Location 740 N MAIN ST <br /> MANTECA, CA 95336 <br /> Phone A2{9-82Z--&%6---X0— r9 c) 20 8 902 <br /> ing Address 740 N MAIN ST <br /> MANTECA, CA 95336 <br /> Care of. -pe- <br /> Location Code 04 - MANTECA Alt Phone <br /> BOS District 003- BESTOLARIDES, STEVE Fax <br /> APN 22302027 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0020330 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name PALUMBO, MIKE (Circle One) <br /> Account Balance as of 10/28/2015: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0520882 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0516123 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0516124 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO534494 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: 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 <br /> EHD Staff: . Date Account out: Date�L <br /> COMMENTS: Neat 0-•,ileC.� 6 ha1C IIIVOICe#: <br />