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Date run 2/18/2015 2:20:44PA SAN JO JIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> \�/ Pagel <br /> Run by <br /> Facility Information as of 2/18/2015 <br /> Record Selection Criteriareality ID FA0017013 <br /> tC3 <br /> ■It E COPY Make changOWNERSHIP CHANGE(date) <br /> in RED ink. <br /> IN <br /> F L FORMATION CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0013854 New Owner ID <br /> Owner Name A SOUZA& SON <br /> Owner DBA A SOUZA&SON <br /> Owner Address 105 E 10TH ST <br /> TRACY, CA 95376 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified / <br /> Mailing Address 2027 WI LUND RD V <br /> TRACY, 95376 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017013 <br /> Facility Name A SOUZA& SON <br /> Location 20274 S WICKLUND RD <br /> TRACY, CA 95376 <br /> Phone 209-835-8330 <br /> Mailing Address 105 E 10TH ST <br /> TRACY, CA 95376 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 20931007 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone \. <br /> Night Phone J <br /> ACCOUNTS RECEIVABLE FILE INFORMATION / \ <br /> Account ID AR0029895 Gam` ��\J New Account ID: <br /> Mail Invoices to Owner 1� i\ ` <br /> Mail Invoices to: Owner / Facility / Account <br /> Account Name A SOUZA& SON �( r `<PSV, (Circle One) <br /> Account Balance as of 2/18/2015: $106.00 <br /> (Circe One) <br /> Transfer to AciveMecNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0526198 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PR0530927 EE0002646-THUY TRAN Inactive Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO530926 EE0002646-THUY TRAIN Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532870 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,acknowledge that all site,Si project specific,PHSIEHD hourly charges associated with this facility <br /> or acivily will be billed to the perry identified as the OWNER on this}orm. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <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 Rewivad by, <br /> REHS: Date /_/ Account out: Date <br /> COMMENTS: <br />