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Date 3/6/2013 10:24:56AM SAN JOArOIN COUNTY ENVIRONMENTAL HEAL1e(DEPARTMENT Report*5021 <br /> Run by Pagel <br /> Facility Information as of 3/6/2013 <br /> Record selection Criteria: Facility ID FA0009138 <br /> Make changes/comections in RED ink. <br /> INFORMATION CHANGE(date) . <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0007138 Case Number: H01479 New owner ID <br /> Owner Name MANTECA AUTO PLAZA <br /> Owner DBA MANTECA AUTO PLAZA <br /> Owner Address 1190 S MAIN ST <br /> MANTECA, CA 95336 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-239-7777 <br /> Mailing Address PO BOX 1286 <br /> MANTECA, CA 95336 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009138 <br /> Facility Name MANTECA AUTO PLAZA <br /> Location 1190 S MAIN ST <br /> MANTECA, CA 95336 <br /> Phone 209-239-7777 �� /! I! 0 ) <br /> Mailing Address PO BOX 1286 <br /> MANTECA, CA 95336 <br /> Care of <br /> Location Code 04 - MANTECA Alt Phone <br /> BOS District 005-ORNELLAS, LEROY Fax <br /> APN 22105023 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name v'f' <br /> Title <br /> Day Phone p <br /> Night Phone ` <br /> ACCOUNTS RECEIVABLE FILE INFORMATION VrCv �V71 n <br /> Account ID AR0016138 ,G',( � New Account ID: <br /> Mail Invoices to Facility J, 1� Maillnvoicesto: Owner / Facility / Account <br /> Account Name MANTECAO PLAZA a <br /> y� (Circle One) <br /> Account Balance as of 316/2013: $ 00 io)— ( /_�^/�_�J) `J <br /> (Circle One) <br /> Transfer to <br /> � Atlive/Inectva <br /> p oI ,,an L"Z3S$py Employee 10 and Name slaws New owner Delete <br /> ili <br /> 1921 -HMBP-Regular-Primary Location RO 70995 EE0002474-MICHAEL PA Active Y N A D <br /> 2220-SM HW GEN<5 TONS/YR PR0513666 EE0002670-MUNIAPPA NAIDU Active Y N A D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOtPRO511426 EE0000000-HAZ MAT SJC GIES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0509138 EE0o00000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0528392 EE0002670-MUNIAPPA NAIDU Active,Exempt Y N A 0 D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO522391 EE0007379-AMANDA BOERTIEN Inactive Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0532252 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,anNor project specific.PHS/EHO hourly charges associstad won this fesolity, <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 seem standards and state andor <br /> Federal Lara <br /> APPLICANT'S 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 Received by <br /> RENS: I I T /�/Yj-b Z'" Date 3 /�(_/� Account out: _ Date I l <br /> COMMEMS: <br />