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Date run 7/7/2008 10:23:54AM SAN JC "JIN COUNTY ENVIRONMENTAL HEA' 'DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 7/7/2008 <br />Record Selection Criteria: Facility ID FA0009628 <br />Make changes/corrections in RED ink or pencil. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0007628 Case Number: H05012 <br />Owner Name <br />TOM HILLIER <br />Owner DBA <br />TOM HILLIER FORD <br />Owner Address <br />3000 MCHENRY AVE <br />209-838-3535 <br />ESCALON, CA 95320 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-838-3535 <br />Mailing Address <br />3000 MCHENRY AVE <br />Y <br />ESCALON, CA 95320 <br />Care of <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARPR0509628 <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0009628 <br />Facility Name <br />TOM HILLIER FORD <br />Location <br />3000 MCHENRY AVE <br />EE0000000 - HAZ MAT SJC OES Inactive <br />ESCALON, CA 95320 <br />Phone <br />209-838-3535 <br />Mailing Address <br />3000 MC HENRY AVE <br />Y <br />ESCALON, CA 95320 <br />Care of <br />Location Code <br />BOS District 005 - ORNELLAS, LEROY <br />APN 247-150-42 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0016628 <br />Mail Invoices to Owner <br />Account Name TOM HILLIER <br />Account Balance as of 7/7/2008: $0.00 <br />Program/Element and Description <br />Record ID Employee ID and Name <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax _ <br />EMail <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Status New Owner? Delete <br />2220 - SM HW GEN <5 TONS/YR PRO517869 <br />EE0002670 - MUNIAPPA NAIDU Active <br />Y <br />N <br />A I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIOPRO511916 <br />EE0000000 - HAZ MAT SJC OES Inactive <br />Y <br />N <br />A I D <br />2244 - PACT TRANSFER RECORD - OES PR0520175 <br />EE0000000 - HAZ MAT SJC OES Active <br />Y <br />N <br />A I D <br />2381 - UST FACILITY (BEFORE 1/84) - obsolete PR0501994 <br />EE0007289 - ALISON YOUNGBLOOD Inactive <br />Y <br />N <br />A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARPR0509628 <br />EE0000000 - HAZ MAT SJC OES Inactive <br />Y <br />N <br />A I D <br />4740 - WASTE TIRE SITE - EXEMPT PR0523296 <br />EE0003611 - FRANK GIRARDI Inactive <br />Y <br />N <br />A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges <br />associated with this <br />facility or activity will be billed to the party identified as the OWNER on this form. I also <br />certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br />State and/or Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: <br />COMMENTS: <br />\\phs-ehsql-nt\apps\envisions\reports\5021. rpt <br />` $20.00 = <br />` $372.00 = _ <br />Amount Paid <br />Amount Paid <br />Date / / Account out: <br />Date <br />Date <br />Date <br />Received by <br />Date <br />