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Date run 12/20/2016 4:45:52P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 12/20/2016 Record Selection Criteria: Facility ID FA0020548 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0016890 Owner Name Armin Ghorbani Owner DBA 25445 S SCHULTE RD Owner Address 27730 LEEWARD WAY Phone TRACY, CA 95304 Home Phone 510-377-5723 Work/Business Phone 209-832-2300 Mailing Address 2705 Auto Plaza Dr Location Code Tracy, CA 95304 Care of GHORBANI, ARMIN FACILITY FILE INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) 2 SSN /Fed Tax ID New Owner ID : Facility ID / CERS ID FA0020548 10187645 Facility Name TRACY COLLISION Location 25445 S SCHULTE RD TRACY, CA 95377 Phone 209-832-2300 x Mailing Address 25445 S SCHULTE RD Status TRACY, CA 95377 Care of GHORBANI, ARMIN Location Code 99 - UNINCORPORATED P Alt Phone BOS District 005 - ELLIOTT, BOB Fax _ APN 20944029 EMail: EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0036752 Mail Invoices to Account Mail Invoices to: Account Name TRACY COLLISION Account Balance as of 12/20/2016: $0.00 New Account ID: : Owner / Facility / Account (Circle One) APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: * $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received by // EHD Staff: Date L'�i �c7 / Account out: Date —/-L/ 2Z ! Y COMMENTS: Invoice #: I 1 41 -Dec- t5 /6 �;,, r. -- F4 - (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete �HMBP-Common Materials PR0535956 EE0000010 - PETER LOMBARDI Active Y N A� D 2220 - SM HW GEN <5 TONS/YR PR0535629 EE0000019 - HERLINDA MENCHACA Inactive Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0535631 Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility 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 and/or Standards and State andlor Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: * $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received by // EHD Staff: Date L'�i �c7 / Account out: Date —/-L/ 2Z ! Y COMMENTS: Invoice #: I 1 41 -Dec- t5 /6 �;,, r. -- F4 -