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/2/8/2017 2:15:33PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report M21 <br /> unby DONNAPapel <br /> Facility Information as of 218/2017 <br /> Record Selection Criteria: Facility ID FA0017944 <br /> Make changeelcon ections in RED ink <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed TaxlD : <br /> Owner ID OW0014740 New Owner ID <br /> Owner Name ELEMENT 6 MOTOR WERKS INC. <br /> Owner DBA ELEMENT 6 MOTOR WERKS INC <br /> Owner Address 21001 SAN RAMON VALLEY BLVD <br /> SAN RAMON. CA 94583 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-239-0639 <br /> Mailing Address 21001 SAN RAMON VALLEY BLVD <br /> SAN RAMON, CA 94583 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0017944 10186715 <br /> Facility Name ELEMENT 6 MOTOR WERKS, INC. <br /> Location 923 Moffat Blvd <br /> MANTECA, CA 95366 <br /> Phone 209-239-0639 x <br /> Mailing Address 923 MOFFAT BLVD <br /> MANTECA, CA 95336 <br /> care of Roberto Cuellar <br /> Location Code 04- MANTECAAlt Phone <br /> BOIS District 005 - ELLIOTT, BOB Fax <br /> APN 22115002 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 AR0031477 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name ELEMENT 6 MOTOR WERKS INC. (Circle one) <br /> Account Balance as of 2/8/2017: $405.00 <br /> (Circle One) <br /> Transfer to Active/Inachne <br /> Program/Element and Description Record ID Employee ID and Name Status New Owni Delete <br /> 1920-HMBP-Common Materials PRO526503 EE0000009-NICHOLAS LOEHRER Active Y N AD <br /> 2220-SM HW GEN<5 TONS/YR PRO538587 EE9999996-THREE VACANT3 Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532164 Inactiv( Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,lire undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly charges associated with thisfscility <br /> or activity will be billed to the party identified as the OWNER on this form. I also certi/y that all operations will be performed In accordance with all applicable Ordinance Codes andor Standards and State end'or <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date I / <br /> Payment Type.. Check Number R ceiv <br /> EHD Staff: ii/N �YT yr— Date / / Account out Date <br /> COMMENTS: CAt/niMi-Ii Vf-f$it31/0/ 7 <br /> Invoice#: <br /> mQ,tn� Y2�UXf1 ttrnove� `� ro �1i, Iraln5 O'� <esS. <br /> s�;tl oQe�G� '••� ? `�1�s� o,���so Tie �auiLr�y iSnod' ove6ottl <br /> The fa�rl/ t st ed 6G ;01 dt , end of DcGei��s ZOId, �e�'� <br /> >h{ 1'� orune �u1!! be �,A�,ny a Clvyrn9 �n <br />