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Dale un 318/2011 3:41:40PM SAN JO'— UIN COUNTY ENVIRONMENTAL HEA' I DEPARTMENT Report#5021 <br /> Ranby ,5290 Facility Information as of 3/8/201Pagel <br /> Record Selection Criteria: Facility ID FAD015009 <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 OW0012006 New Owner ID <br /> Owner Name PACIFIC COAST MS INDUSTRIES IN <br /> Owner DBA PACIFIC COAST MS INDUSTRIES <br /> Owner Address 4101 N HOLLY DR <br /> TRACY, CA 95304 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 1020 <br /> LEBANON, KY 400335020 <br /> Care of <br /> FACILITY FILE INFORMATION nnnn// <br /> Facility ID FA0015009 <br /> Facility Name PACIFIC COAST MS INDUSTRIES <br /> Location 3940 COMMERCIAL ST <br /> TRACY, CA 95376 <br /> Phone 209-836-9624 <br /> Mailing Address PO BOX 1020 <br /> LEBANON, KY 400335020 <br /> Care of <br /> Location Code AR 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 AR0025645 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name PACIFIC COAST MS INDUSTRIES (Cirde Ona) <br /> Account Balance as of 3/8/2011: $547 <br /> (Circle One) <br /> Transfer to Activelinactve <br /> Program/Element and Description R ID Employee ID and Name Status New Omer? O tete <br /> 2220-SM HW GEN<5 TONS/YR PRO522377 EE0002646-THUY TRAN Active Y N A 1 D <br /> 2244-PACT TRANSFER RECORD-DES PRO522037 Active Y N I <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPR0532693 Active Y N 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/EHO hourly charges ass this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also certify Nat all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State andlor Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Data <br /> Payment Type Check Number Received b <br /> RENS: ��i _ O /_ Date /.,A / I Account out: > Date <br /> COMMENTS: u[`�tel.l� <br /> ` a ' 'J <br /> /lam . <br /> \\eh�nv\envisionlreportst5021.rpt <br />