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W. 23, 2013_11:22AM_Sa-P Joaquin County No. 2914 P. 1 <br /> -'diem`, 412312013 11:20:56A1 SAN K'11is N COUNTY ENVIRONMENTAL HEALTi�'PARTMENT Rzpoa tuo` 21 <br /> Ron by <br /> Facility Inforniat[o as of 4/23/2013 Paga1 <br /> Rdcmd Selection Crilede: Fa�c/tmry�10 FA0009948 <br /> Make chan9es/oorrectiens in RED Ink, <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION <br /> OWNERSHIP CHANGE(date) —/-02.�1/� <br /> SSN/Fed Tax Io <br /> owner ID OW0007948 Case Number: H05077 New owner ID : - 0 -7 / s <br /> Owner Name A&AROSSIHAY SERVICE <br /> Owner DBA <br /> OwnerAddress 299 N AIRPORT WAY <br /> MANTECA, CA 95336 <br /> Home Phone 209-609-6954 <br /> Work79usiness Phone 209-823-3965 <br /> Mailing Address PO BOX 332 <br /> MANTECA, CA 95336 <br /> care of A&A ROSS] HAY SERVICE (. „r p�,j Kjue /`1,f7 <br /> FACILITY PILE INFORMATION <br /> FacilitylD/CERS ID FA0009948 10,183,053 <br /> Faclllty Name A&A ROSS[ HAY SERVICE rj GP NP�CdU Cb <br /> Location 299 N AIRPORT WAY --�--�— <br /> MANTECA, CA 95336 <br /> Phone 209-823-3965 <br /> Mailing Address PO BOX 332 <br /> MANTECA, CA 95336 <br /> Care of <br /> Location Code 04-MANTECA Alt Phone <br /> B08 District 003-BESTOLARIDES Fax <br /> APN 19816021 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title S6 <br /> Day Phone <br /> NIghE Phone -- <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> AccountfD AR0016948 New Account ID- <br /> Mall Invoices to Facility Mall Invoices to: Owner i Facility / Account <br /> Account Name A&A ROSS[HAY SERVICE tokde e, <br /> Account Balance <br /> was/ Pof 4///23/2013: $6,566.10 <br /> I rU/VV O r L�.�"S 4D AF..D03 = ?)2 , (Grtle Cna, <br /> PragremrElemedl and o98ddptidn Record lD Employee to cad Name BIaWs Transfer to Alivellfls Ne <br /> New Omnen Delole <br /> 1921-HMBP-Regular-Primary Location PRO619980 EE0002474-MICHAEL PAR1881 Ac5ve Y N A I D <br /> 2220-SMHWGENc5TON3/YR PRO514106 E20002846-THUY TRAN Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORMATIOlPR0512236 EE0000000-HAZ MAT SJC 05S Inactive <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR0oR0509946 Y N A I D <br /> EE0000000-HAZ MAT SJCOES Inactive Y N A I D <br /> 2832-AST FAC 10K-U=100 K GAL CUMULATIVEPR0515679 EE0002646-THVY TRAN Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO535794 E20007379-AMANDA BOERTIEN Active Y N A I D <br /> ERSG-ELECTRONIC REPORTING STATE SURCH,PRO531371 - Inactive Y N A I D <br /> BILLING and COMnMNCE AGKNOWLEDGEMEm*. I,Ilse odderelgned owner,aperalprw aaentorsamg acatrlowlsdga mel all ace,a,dror project specdlq PHB/EHo War",a asseciele <br /> dfadiVfydwlN Vda facility <br /> Ml be billed to lne pMy Wenlided as U00NnIERonis rem telsd cedlfy Nal all dparallonawlll b mrormed in edautlence wiNell appliwbld Ordinance Codec ender Slsndads and Slala endor <br /> Federal Lama. <br /> APPLICANTS SIGNATURE: . Z Sf" 2 r C .2 J L�L'J/ RFgyM <br /> Date A T <br /> Program Records to be TRANSFEREO: `$25.00= Amount Paid �Ob — Date r( /�! /15 S �/�/ 0 <br /> water System to be TgANSFERED: Amount Paid Date /_� '9N� 1 g <br /> Payment Type ✓ Check Number �) O Receivedb yE4'y'h°q'�Qc,/ <br /> RENS: Date�J 1 Account out: _ j Date /�f �j OFpMF OV <br /> CQMMENrg <br /> �v12 � l1S � �3 <br />