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Date ran 6/19/2014 12:01:46PI SAN JOIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by 1273 Pagel <br /> Facility Information as of 6/19/2014 <br /> Record Selection Criteria: Facility ID FA0022180 <br /> Make changeslcorrectlons in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0018348 New Owner ID <br /> Owner Name VALENTINE, TIMOTHY <br /> Owner DBA VALENTINE CONSTRUCTION <br /> Owner Address 22&OAK ST D r� <br /> ,r <br /> MANTECA, CA 95337 <br /> Home Phone 209-602-3901 <br /> Work/Business Phone Not Specified <br /> Mailing Address -22firOAK ST oZ 6 <br /> MANTECA, CA 95337 <br /> Care of VALENTINE, TIMOTHY <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID/CERS ID FA0022180 <br /> FacilityName VALENTINE CONSTRUCTION <br /> Location 221 OAK ST <br /> MANTECA, CA 95337 <br /> Phone 209-602-3901 �I <br /> .may Mailing Address-226 OAK ST a,5 / <br /> / MANTECA, CA 95337 <br /> Care of VALENTINE, TIMOTHY <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 21939018 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 AR0040427 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name VALENTINE CONSTRUCTION (Circle One) <br /> Account Balance as of 6/19/2014: $312.50 <br /> (Cirde One) <br /> Transferlo Active/Inacive <br /> ProgramrElement and Description Record ID Employee ID and Name Slalus New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0538392 EE0001699-JOHNNY YOAKUM Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project spefc,PHSrEHD 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 ander Standards and State andor <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 Type Check Number Race <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />