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Date win, 3/7/2911 4:13:46PM SAN JOWIN COUNTY ENVIRONMENTAL HEAW <br /> f DEPARTMENT Report usort <br /> Run by 4000, Pagel <br /> Facility Information as of 3/7/20 <br /> Record Selection Criteria: Facility ID FA00110'12 <br /> 5�✓� FILE Make changes/corrections in RED Ink. <br /> I D I INFORMATION CHANGE(date) <br /> r_ OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0009012 Case Number: H09152 New Owner ID <br /> Owner Name PACIFIC COAST MS INDUSTRIES IN <br /> Owner DBA PACIFIC COAST MS INDUSTRIES IN <br /> Owner Address 4101 N HOLLY DR <br /> TRACY, CA 95304 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-836-9624 <br /> Mailing Address P8-BOX-1081 a Dam <br /> THp 3T& LEBAl ��y �FO033 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0011012 <br /> Facility Name PACIFIC COAST INDUSTRIES <br /> Location 4101 N HOLLY DR <br /> TRACY, CA 95376 <br /> Phone 209-836-9624 <br /> Mailing Address <br /> T <br /> Care of <br /> Location Code Alt Phone <br /> BOS District 005-ORNELLAS, LEROY Fax <br /> APN 21222007 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0018012 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> ci Ue one) <br /> Account Name PACIFIC COAST INDUSTRIES <br /> Account Balance as of 3/7/2011: $622.00 (Circle One) <br /> Transfer to Active/Inaclve <br /> Program/Element and Description <br /> Record ID Employee ID and Name Status New Owner? tete <br /> 2220-SM HW GEN<5 TONS/YR PRO514490 EE0002646-THUY TRAN Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513300 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PR0521195 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARIPR0511012 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPRO533545 Active Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to me party Identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> state and/or Federal Laws. D �7 <br /> APPLICANT'S SIGNATURE: �l L- F�"-T'4-) Date --O—/--7 f <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment TypeCheck Number Receiv b <br /> REHS: FIT— Date_Aa/_2q/ _ Account out: Date�l -1 !1<L <br /> COMMENTS: 1 r.D.. / {/�� S e,1%� �Kl A ,(l ,r, <br /> _FU-Y�C lav ((( �fJ` <br /> Ueh-env\envision\repports\5021.rpt <br />