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Date ren 9/3/2013 4:07:28PM SAN JOi JIN COUNTY ENVIRONMENTAL HEAI DEPARTm fl L E <br /> 98f Y <br /> Run by i <br /> Facility Information as of 9/3/2013 <br /> Record Selection Criteria: Facility ID FA0012457 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) - <br /> OWNERSHIP CHANGE(date) f7_It7' . IZ <br /> OWNER FILE INFORMATION SSN/Fed Tax ID : <br /> Owner ID OW0009662 NeVy <br /> wne ID <br /> Owner Name ,�^, 1zArJ(� (fib I e, <br /> Owner DBA <br /> Owner Address 710 E YOSEMITE AVE <br /> MANTECA, CA 953365827 <br /> Home Phone 209-838-2621 <br /> Work/Business Phone 209-825-7340 <br /> Mailing Address 710 E YOSEMITE AVE <br /> MANTECA, CA 953365827 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0012457 10,184,267 <br /> Facility Name J K AUTOMOTIVE <br /> Location 710 E YOSEMITE AVE <br /> MANTECA, CA 953365827 <br /> Phone 209-825-7340 <br /> Mailing Address 710 E YOSEMITE AVE <br /> MANTECA, CA 953365827 { <br /> Care of i(?� <br /> Location Code 04- MANTECA Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN 22111037 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 AR0020314 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name J K AUTOMOTIVE (Circle One) <br /> Account Balance as of 9/3/2013: $3,180.75 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0520822 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0516095 EE0009001 -ELENA MANZO Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0516096 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0516097 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532298 Inactive 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 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 andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Typr9�� Check Number Received by <br /> REHS: �G� C, r Date / / if Account out: Date <br /> COMMENTS: <br />