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Date nm 7/1/2010 10:18:52AM SAN X )lUIN COUNTY ENVIRONMENTAL HEA i DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/1/2010 <br /> Record Selection Criteria: Facility ID FA0010470 <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 /> BOIS District 005-ORNELLAS, LEROY Fax <br /> APN 22119002 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title -40yg3 <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017470 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility I Account <br /> Account Name POLIMENO, JOHN (Circle One) <br /> Account Balance as of 7/1/2010: $821.50 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element ark Description Record ID Employee ID and Name Status New OwneR Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO514339 EE0002646-THUY TRAN Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512758 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PRO520337 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPROSID470 EEOOOOOOO-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PRO531286 Active Y N A I D <br /> BILLING antl COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that ad site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facdily or activity wa be billed to the party identified as the OWNER on this torte. I also certify that all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> State anchor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 7 I 7 <br /> Program Records to be TRA FERED: -$20.00= Amount Pail Date / I <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date / / <br /> Payment Type Check Number Recti y _ <br /> REHS: �'I4 r nL41/1'd.- Date -7 10 A000unt out: Date 115-1 <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />