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r" <br /> G;31e run %3/11/2014 9:44:42AR SAN JO` %N'i COUNTY ENVIRONMENTAL HEAIASMOP DEPARTMENT <br /> Run b Report#5021 <br /> Y <br /> Facility Information as of 3/11/2014 Pagel <br /> Record Selection Criteria: Facility tD FA0017408 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0014249 New Owner ID <br /> Owner Name MANUEL SILVA <br /> Owner DBA MANUEL SILVA <br /> Owner Address 2091 E GRANT LINE RD <br /> TRACY, CA 95304 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 2091 E GRANT LINE RD <br /> TRACY, CA 95304 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0017408 10186407 <br /> Facility Name MANUEL SILVA <br /> Location 24080 S BIRD RD <br /> TRACY, CA 95304 <br /> Phone 209-836-3440 x0 <br /> Mailing Address 2091 E GRANT LINE RD <br /> TRACY, CA 95304 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN 23910008 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE RLE INFORMATION <br /> Account ID AR0030290 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner 1 Facility I Account <br /> Account Name MANUEL SILVA (Circle One) <br /> Account Balance as of 3/11/2014: $53-E10- <br /> (Circle One) <br /> Transferto Activellnactve <br /> ProgramlFlement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PRO525593 Active Y N AI D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0529297 EE0000753-WILLY NG Active,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532814 Inactive Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I pIso certify that all operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! / <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date 1 / <br /> Water System to be TRANSFERED: Amount Paid Date 1 I <br /> Payment Type Check Number Receiv by <br /> REHS: k.A1• ICU Date 1 I 1 /may Account out: _ Date 3 l _ ! <br /> COMMENTS: <br /> U� i t11q <br /> OttiG�"h 1 K e-S <br />