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Date run 21112016 2:50:10PMReport#5021 <br /> SAN J IN COUNTY ENVIRONMENTAL HEA DEPARTMENT <br /> Run by Pagel <br /> Facility Information as of 21112016 <br /> Record Selection Criteria: Facility I FA0010091 <br /> Make Changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN1 Fed Tax ID <br /> Owner ID OW0008091 Case Number: H06516 New Owner ID <br /> Owner Name Adam Ballard <br /> Owner DBA SPEEDEE OIL CHANGE &TUNE-UP <br /> Owner Address 245 W LOUISE AVE <br /> MANTECA, CA 95336 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-612-6056 <br /> Mailing Address 3505 Blackhawk Ct <br /> modesto, CA 95356 <br /> Care of BALLARD, MITCH <br /> FACILITY FILE INFORMATION <br /> Facility ID l CERS ID FA0010091 10183201 <br /> Facility Name SPEEDEE OIL CHANGE &TUNE-UP-MTCA <br /> Location 345 W LOUISE AVE <br /> MANTECA, CA 95336 <br /> Phone 209-825-5823 x <br /> Mailing Address 245 W LOUISE AVE <br /> MANTECA, CA 95336 <br /> Care of BALLARD, Adam <br /> Location Code 04 - MANTECA Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax , <br /> APN 21635016 EMail: d <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017091 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner ! Facility / Account <br /> Account Name SPEEDEE OIL CHANGE &TUNE-UP-MTCA (Circle One) <br /> Account Balance as of 211/2016: $0.00 <br /> (Circle One) <br /> Transforto Activellcactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0520067 EE®000009-NICHOLAS LOEHRER Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512379 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2229-GEN 50<250 TONS PERMIT PR0514165 EE0009001 -ELENA MANZO Active Y N A I D <br /> 2332-EXEMPT TANK FACILITY PRO515804 EE0009001 -ELENA MANZO Active,I Y N A 1Z) D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510091 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531494 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,Dperator or agent of same,acknowledge that all site,andror project specific,PHSlEHD 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 andlor Standards and State andror <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received b <br /> EHD Staff: Date 1Account out: Date ! 1 ! <br /> COMMENTS: <br /> Invoice#: <br /> Z3 3 <br /> tq 5q-0-7!571r <br />