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Date run 8/20/2015 9:31:25Ah SAN Jf UIN COUNTY ENVIRONMENTAL HE H DEPARTMENT Report#5021 <br /> Run by '" Pagel <br /> Facility Information as of 8/20/2015 <br /> Record Selection Criteria: Facility ID FA0018972 <br /> Make changestcorrections 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 OW0015609 New Owner ID <br /> Owner Name JOSEPH R GRAW <br /> Owner DBA JOE'S SMOG SHACK&AUTO <br /> Owner Address 500 E TENTH ST <br /> TRACY, CA 95376 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-814-4766 <br /> Mailing Address PO BOX 1194 <br /> TRACY, CA 95378 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0018972 10187017 <br /> Facility Name JOSS SMOG SHACK INC. <br /> Location 500 E TENTH ST UNIT E <br /> TRACY, CA 95376 <br /> Phone 209-836-4766 x0 <br /> Mailing Address PO BOX 1194 <br /> TRACY, CA 95378 <br /> Care of Joseph Graw <br /> Location Code Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN 23519015 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 AR0033752 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner 1 Facility I Account <br /> Account Name JOES SMOG SHACK INC. (Circle One) <br /> Account Balance as of 8/2012015: $0.00 <br /> (Circle One) <br /> Transfer to Aciivefinactve <br /> ProgrenVElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO528002 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONSIYR PRO538544 EE0002646-THUY TRAIN Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532415 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 Godes and/or Standards and State andtor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I 1 <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date I 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date 1 1 Account out: Date / <br /> COMMENTS: <br /> Invoice#: <br />