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Date run 10/21/2010 2:35:06P SAN JUIN COUNTY ENVIRONMENTAL HEI DEPARTMENT Report#5021 <br /> Run by Pagel <br /> ' Facility Information as of 10/21/20 U g <br /> Record Selection Criteria: Facility ID FA0014454 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0011496 New Owner ID <br /> Owner Name FLEETWASH <br /> Owner DBA FLEETWASH <br /> Owner Address 1162 BESSEMER AVE <br /> MANTECA, CA 95337 <br /> Home Phone Not Specified <br /> Work/Business Phone 800-847-3735 <br /> Mailing Address PO BOX 1577 <br /> W CALDWELL, NJ 07007 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014454 <br /> Facility Name FLEETWASH <br /> Location 1162 BESSEMER AVE#2 <br /> MANTECA, CA 95337 <br /> Phone 209-823-8775 <br /> Mailing Address PO BOX 1577 <br /> W CALDWELL, NJ 07007 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0024534 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name FLEETWASH (Circle One) <br /> Account Balance as of 10/21/2010: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inach e <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2244-PACT TRANSFER RECORD-DES PRO519312 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO535074 EE0002620-ALFONSO ARAMBULA Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PRO532868 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersignetl owner,operator or agent of same,acknoWedge that all site,amllor project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all eperaaons vdll be performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <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 Receiv <br /> REHS: P" - Date 10 / 21 / 0 Accountout: Date 1WRIZZ2 <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />