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Date run 2/1/2013 11:30:45AM SAN JON.,JIN COUNTY ENVIRONMENTAL HEAT, DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/1/2013 <br /> Record Selection Criteria: Facility 10 FA00I D470 <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 OW0008470 Case Number: H08165 New Owner ID <br /> Owner Name POLIMENO, JOHN <br /> Owner DBA ELEGANT SURFACES <br /> Owner Address 551 CARNEGIE ST <br /> MANTECA, CA 95337 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-823-9388 <br /> Mailing Address 551 CARNEGIE ST <br /> MANTECA, CA 95337 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010470 <br /> Facility Name ELEGANT SURFACES <br /> Location 551 CARNEGIE ST <br /> MANTECA, CA 95337 <br /> Phone 209-823-9388 <br /> Mailing Address 551 CARNEGIE ST <br /> MANTECA, CA 95337 <br /> Care of <br /> Location Code 04 -MANTECA Alt Phone <br /> BOS District 005-ORNELLAS, LEROY Fax <br /> APN 22119064 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 AR0017470 NevvAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner I Facility / Account <br /> Account Name POLIMENO, N (Circle One) <br /> Account Balance as of 2/1/2013: $6 .00 <br /> (amts one) <br /> Mt'A� <br /> Transfer to ell <br /> AcWnacNe <br /> Program/Elemenl and Description R rd ID Employee ID and Name Status Naw Owner? Delete <br /> MBP-Regular-Primary Location PR0520337 EE0002474-MICHAEL PARISSI Active Y N A l D <br /> 2220 JM HW GEN<5 TONS/YR PR0514339 EE0002670-MUNIAPPA NAIDU Active Y N A �j D <br /> -HAZ MAT BUSINESS PLAN AUTHORIZATIOtPRO512758 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARCPR0510470 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0531286 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,ac ledge that all site,and'or project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identfied as the OWNER on this form I also certify that all operations wi11 ba performed in accordance win all applicable Ordinance Codes ander Standards and State andor <br /> 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 Recely d by <br /> REHS: Date lI Account out: — Z Date �t)� <br /> COMMENTS. v <br /> ;r- �L� />ti�lLr i �.,,s�,' /��L � ��� ����t2 �n�aP 7x113 13 <br /> L41 <br />