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Date rue 8/18/2015 8:46:48AIv SAN il COUNTY ENVIRONMENTAL HE*H DEPARTMENT <br /> Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/18/2015 <br /> Record Selection Criteria: Facility ID FA0010539 <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 SSN/Fed Tax ID <br /> Owner ID OW0012578 New Owner ID <br /> Owner Name Chris Thode <br /> Owner DBA JC AUTOMOTIVE <br /> OwnerAddress 760 N MAIN ST <br /> MANTECA, CA 95336 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-482-0496 <br /> Mailing Address 760 N MAIN ST <br /> MANTECA, CA 95336 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0010539 10183633 <br /> Facility Name JCAUTOMOTIVE <br /> Location 760 N MAIN ST <br /> MANTECA, CA 95336 <br /> Phone 209-239-2263 x <br /> Mailing Address 760 N MAIN ST <br /> MANTECA, CA 95336 <br /> Care of John C. Thode <br /> Location Code 04- MANTECA Alt Phone <br /> BOS District 003-BESTOLARIDES, STEVE Fax <br /> APN 22302030 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 AR0017539 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility I Account <br /> Account Name Chris Thode (Circle One) <br /> Account Balance as of 8/18/2015: $0.00 <br /> (Circle One) <br /> Transferlo Activehiactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0512827 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PR0514371 EE0009001 -ELENA MANZO Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0510539 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0523157 EE0002622-BENJAMIN ESCOTTO Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0534633 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 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 ander Standards and State andor <br /> Federal Laws, <br /> APPLICANTS 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 / I <br /> COMMENTS: Invoice#: <br />