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Date run 218/2012 10:T4:05AM SAN JO--4U]N COUNTY ENVIRONMENTAL HEA] T',�DEPARTMENT Report#5021 <br /> Ru0br--- %%00.1 Pagel <br /> Facility Information as of 21812EI'R� <br /> Record Selection Criteria: Facility ID FA0017499 <br /> Make changeslcorrectiom in RED ink. <br /> INFORMATION CHANGE(date) Z M L <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN I Fed Tax ID <br /> Owner ID OW0014340 New Owner ID <br /> Owner Name RYAN COSTA <br /> Owner DBA RYAN COSTA <br /> Owner Address a <br /> MODEST 50 YV1�tn�eca . �� q S3�–70[op <br /> Home Phone Not SpeCified <br /> WorltlBusiness Phone Npt SpECified <br /> Mailing Address '182 ASCOT—6-A I T%Gw t U r <br /> a <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017499 <br /> Facility Name RYAN COSTA <br /> Location 14888 PRESCOTT RD <br /> MANTECA, CA 95336 <br /> Phone 209522-8835 x0 ` <br /> Mailing Address R [ i m l I �t.L'Z'C{ t 1U r/l.,?m <br /> vin z—N z UA — ea,-11-41LD007 <br /> Care of <br /> Locatiorr Code Alt Phone <br /> BOSS District Fax <br /> Am 20611010 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Accourtt ID AR0030381 New Account ID: <br /> RUI Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name RYAN COSTA (Circle One) <br /> Account Balance as of 2/812()12: $280.00 <br /> (Circle One) <br /> Program/Element and Description Record JD Employee ID and Name Status �O Owner? Delet e <br /> 222D-SIU I IW GEN<5 TONSNR PRO530538 EE0002670-MUNIAPPA NAIDU Active Y N A 1 D <br /> 2223-AGWCULTURAL HAZ MAT STORAGE FAGILPRO525684 Active Y N A I D <br /> 284D-AST EXEMPT FRC < 1,320 GAL PRO530537 EE00o2670-MUNIAPPA NAIDU Active,Exempt Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPRO531545 Active Y N A 1 D <br /> BILLING andCOUPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific.PHSIEHD hourly charges associatedwith this <br /> faality or activity will be billed to the party identttied as the OWNER on this form. I also certify that all operations will be performed in accordance with ail applicable Ordinate Codes and/or Standards and <br /> State and7or Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date ! I <br /> Water System to be TRANSFERED. Amount Paid Date <br /> Payment Type Check Nitimber Receivved by <br /> RENS: Date 1 1 Account out: Date 21�1� <br /> COMMENT& <br /> Ileh-envlenvisionlreports15021.rpt <br />