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Date run , 2/1512011 2:33:OOP11 SAN JO! ,VIN COUNTY ENVIRONMENTAL HEAL' ':DEPARTMENT <br /> Report 65021 <br /> Run by ` Pagel <br /> Facility Information as of 2/15/20)-T' <br /> Record Selection Criteria: Facility ID FA0015009 <br /> Make changes/corrections in RED ink. G1 Z <br /> GE(date) <br /> F- E INFORMATION OWNERHIP CHANGE (date) D✓ I <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 44iq�� (2) cr-6 c' Z'r) <br /> T \ elociv.en LA0D 'n3 -507117 <br /> Care of <br /> FACILITY FILE INFORMATION <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 4101 N HOLLY DR <br /> TRACY, CA 95304 <br /> Care of <br /> Location Code Ah 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 [ (CWe One) <br /> Account Balance as of 2/15/2011: $W-O, � A,,,, (7) <br /> ""'� C�"`7� '( (Circle One) <br /> Transfer to Active/Inactve <br /> ram/Element and Description Record to Employee ID and Name Status New Owner? Delete <br /> 2220-);M HW GEN<5 TONS/YR PR0522377 EE0002646-THUY TRAN Active Y N A0 D <br /> ACT TRANSFER RECORD-OES PR0522037 Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0532693 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project speck.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 operations will De performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> Slate and/or Federal Laws. <br /> APPLICANTQ S SIGNATURE: S 2 0-1 ii� 01-\` a cp <br /> �. x� 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 Received by <br /> RENS: l nn 11� Date K: /l I A Account out: <br /> M NTS: <br /> 03 � Ian n Ld t� o-Fl vzrrz�fi`r ✓i <br /> i>161c r�D 1l+� 5. Hca t ee <br /> \\eh-env\envision\reports\5021.rpt <br />