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Date mm 3/11/2015 3:57:47PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report*5021 <br /> Run by Pagel <br /> Facility Information as of 3/11/2015 <br /> Record Selection Criteria: Facility ID FA0017944 <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 10 <br /> Owner ID OW0014740 New Owner ID <br /> Owner Name JOHN VANDERWERFF <br /> Owner DBA HONEST AUTOMOTIVE <br /> Owner Address 923 MOFFAT BLVD <br /> MANTECA, CA 95336 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-679-9012 <br /> Mailing Address 923 MOFFAT BLVD <br /> MANTECA, CA 95336 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017944 10186715 <br /> Facility Name HONEST AUTOMOTIVE <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 John VanderWerif <br /> Location Code 04-MANTECA Alt Phone <br /> BOB District 005-ELLIOTT, BOB Fax <br /> APN 22115002 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> ContactName ,� �,� - &7u-yo,L �J <br /> Title 1"t jµt y�- <br /> Day Phone L <br /> Night Phone31 <br /> ACCOUNTS RECEIVABLE FILE INFOF Iz <br /> I <br /> Account ID AR00314' �//i �� New AccountlD: <br /> Mail Invoices to Owner / Mail Invoices to: Owner / Facility / Account <br /> Account Name JOHN VA 61'�/'�[�, L (-[,, (Circle One) <br /> Account Balance as of 3/11/2015: $363.00 <br /> (Circle One) <br /> Transfer to Activa Inache <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO526503 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN c5 TONSNR PR0538587 EE0009001 -ELENA MANZO Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532164 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 activiy will be billed to the pant identified as Ne OWNER on this form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and State anNar <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 /> REHS: Date_/ / Account out: Date <br /> COMMENTS: .}^�/ wu m <br />