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Date run 3/10/2014 11:35:31AI SAN JO, ;IN COUNTY ENVIRONMENTAL HEA' DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 3/10/2014 <br />Record Selection Criteria: Facility ID FA0012339 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0009572 <br />Owner Name <br />MAUSUMI, OMAR <br />Owner DBA <br />Owner Address <br />19835 PATTERSON PASS RD 308 <br />PR0518856 <br />TRACY, CA 95377 <br />Home Phone <br />510-329-2482 <br />Work/Business Phone <br />209-858-4216 <br />Mailing Address <br />19835 PATTERSON PASS RD <br />EE0002646 - THUY TRAN <br />TRACY, CA 95377 <br />Care of <br />MAUSUMI, OMAR <br />FACILITY FILE INFORMATION <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F <br />Facility ID / CERS ID <br />FA0012339 10184187 <br />Facility Name <br />MANTECA AUTO DISMANTLERS <br />Location <br />3737 W YOSEMITE AVE <br />' <br />LATHROP, CA 95330 <br />Phone <br />209-858-4216 <br />Mailing Address <br />19835 PATTERSON PASS RD <br />I D <br />TRACY, CA 95377 <br />Care of <br />MAUSUMI, OMAR <br />Location Code <br />99 - UNINCORPORATED P <br />Bos District <br />003 - BESTOLARIDES <br />APN <br />24139020 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name GOE, THOMAS H <br />Title <br />Day Phone 209-858-4216 <br />Night Phone 209-858-4216 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN/ Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Account ID AR0020160 <br />Mail Invoices to Facility Mail Invoices to <br />Account Name MANTECA AUTO DISMANTLERS <br />Account Balance as of 3/10/2014: $608.00 <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description <br />Record ID <br />Employee ID and Name <br />Status <br />New Owner? <br />Delete <br />1921 - HMBP-Regular-Primary Location <br />PR0518856 <br />EE0002474 - MICHAEL PARISSI <br />Active <br />Y N <br />A <br />I D <br />2220 - SM HW GEN <5 TONS/YR <br />PR0515767 <br />EE0002646 - THUY TRAN <br />Active <br />Y N <br />A <br />I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F <br />PR0516173 <br />EE0007289 - ALISON YOUNGBLOOD <br />Inactive <br />Y N <br />A <br />I D <br />4740 - WASTE TIRE SITE - EXEMPT <br />PR0523973 <br />EE0009000 - HARPRIT MATTU <br />Active <br />Y N <br />A <br />I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG <br />PR0534432 <br />Inactive <br />Y N <br />A <br />I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, <br />PHS/EHD 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 Codes and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: Date <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />RENS: <br />COMMENTS: <br />' $25.00 = <br />Date <br />Amount Paid Date <br />Amount Paid Date / ! <br />Received y <br />_ Account out: Date //0 /� <br />pk4' <br />i —� <br />