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Date run 8/26/2015 8:45:32AN SAN QUIN COUNTY ENVIRONMENTAL H1 I H DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/26/2015 <br /> Record Selection Criteria: Facility ID FAD017750 <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 1 Fed Tax ID <br /> Owner ID OW0014577 New Owner ID <br /> Owner Name JACK WILLIAMSON <br /> Owner DBA JACK'S TRANSMISSION REPAIR <br /> OwnerAddress 275 MOFFAT BLVD <br /> MANTECA, CA 95336 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-471-0964 <br /> Mailing Address 275 MOFFAT BLVD <br /> MANTECA, CA 95336 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0017750 10186673 <br /> Facility Name JACKS TRANSMISSION REPAIR <br /> Location 275 MOFFAT BLVD <br /> MANTECA, CA 95336 <br /> Phone 209-471-0965 x <br /> Mailing Address 275 MOFFAT BLVD <br /> MANTECA, CA 95336 <br /> Care of JACK WILLIAMSON <br /> Location Code 04 - MANTECA Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN 22106016 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030970 NewAcceunt ID: <br /> Mail Invoices to Account Mail Invoices to: Owner I Facility 1 Account <br /> Account Name JACK WILLIAMSON (Circle One) <br /> Account Balance as Of 812612015: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO526229 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0534836 EE0009001 -ELENA MANZO Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0531829 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT, I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor 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 andlor Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date I I <br /> Payment Type Check Number Received by <br /> EHD Staff: Date I I Account out: Date 1 1 <br /> COMMENTS: <br /> Invoice�: <br />