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Date run 10/15/2013 3:57:23F SAN JUIN COUNTY ENVIRONMENTAL HEA*DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/15/2013 <br /> Record Selection Criteria: Facility ID FA0021980 <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 OW0018096 New Owner ID <br /> Owner Name AUSTIN ROAD BUSINESS PARTNERS <br /> Owner DBA <br /> Owner Address 1463 MOFFAT BLVD STE 5 <br /> MANTECA, CA 95336 <br /> Home Phone 209-456-4148 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1463 MOFFAT BLVD STE 5 <br /> MANTECA, CA 95336 <br /> Care of BILL FILIOS (PARTNER) <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021980 <br /> Facility Name SR-99 AUSTIN RD INTERCHANGE ROW IMI <br /> Location 20081 AUSTIN RD <br /> MANTECA, CA 95336 <br /> Phone <br /> Mailing Address 1463 MOFFAT BLVD STE 5 <br /> MANTECA, CA 95336 <br /> Care of BILL FILIOS (PARTNER) <br /> Location Code 04 - MANTECA Alt Phone <br /> BOS District 005- ELLIOTT, BOB Fax <br /> APN 22805003 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name BILL FILIOS (PARTNER) <br /> Title <br /> Day Phone 209-456-4148 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0040075 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name BLACKBURN CONSULTING (Circle One) <br /> Account Balance as of 10/15/2013: $0.00 <br /> (Circle One) <br /> Transfer to Activetlnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2956-ABANDONED HW SITE PR0538059 EE0001699-JOHNNY YOAKUM Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / 1 <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 /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />