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Dale run 3/24/2015 11:32:10A1 SAN JOIN COUNTY ENVIRONMENTAL HEA*DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/24/2015 <br /> Record Selection Catena: Facility ID FA0014300 <br /> Make changelslcorrections 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 OW0011354 New Owner ID <br /> Owner Name DAN PETKER/TIM HARRIS <br /> Owner DBA BROOKS AUTO BODY <br /> Owner Address 941 MOFFAT BLVD <br /> MANTECA, CA 95336 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-8234452 <br /> Mailing Address 941 MOFFAT BLVD <br /> MANTECA, CA 95336 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0014300 10184595 <br /> Facility Name BROOKS AUTO BODY <br /> Location 941 MOFFAT BLVD <br /> MANTECA, CA 95336 <br /> Phone 209-823-4452 x0 <br /> Mailing Address 941 MOFFAT BLVD <br /> MANTECA, CA 95336 <br /> care of DAN PETKER <br /> Location Code Alt Phone <br /> BOS District Fax <br /> Al 22115011 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 AR0024286 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name DAN PETKER/TIM HARRIS (Circle One) <br /> Account Balance as of 3/24/2015: $0.00 <br /> (Circe Ona) <br /> Transfer to Active/Inactve <br /> Program/Element and Descrption Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO621261 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO523364 EE0009001 -ELENA MANZO Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO519173 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532541 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror 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 forthl also certifythat all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State andlor <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 /> REHS: Date_/_/_ Account out: Date <br /> COMMENTS: <br />