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Date ran 9/4/2013 2:08:25PM SAN J*UIN COUNTY ENVIRONMENTAL HEA`I DEPARTMENT <br /> Run by Report#5021 <br /> Facility Information as Of 9/4/2013 Pagel <br /> Record Selection Criteria: Facility ID FA0021568 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID OW0017730 New Owner ID <br /> Owner Name ELDER, FASSEL (PHIILIP) <br /> Owner DBA <br /> Owner Address 837 SHAW RD <br /> STOCKTON, CA 95215 <br /> Home Phone 209-662-0952 <br /> Work/Business Phone Not Specified <br /> Mailing Address 837 SHAW RD <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0021568 <br /> Facility Name FORMER RAINWATER CAR WASH <br /> Location 420 W YOSEMITE AVE <br /> MANTECA, CA 95336 <br /> Phone <br /> Mailing Address 837 SHAW RD <br /> STOCKTON, CA 95215 <br /> Care of <br /> Location Code 04- MANTECA Alt Phone <br /> BOS District 005- ELLIOTT, BOB Fax <br /> APN 21931206 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 AR0039041 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name AMI ADINI &ASSOCIATES, INC (Circle One) <br /> Account Balance as of 9/4/2013: $-1,875.00 <br /> (Circle One) <br /> Program'Element and Description Record ID Employee ID and NameTransfer to AcaveAnactve <br /> Status New Owner? Delete <br /> 2957-UST FILE-RWQCB PRO537485 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,andbr 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 Ialso certify that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State andbr <br /> Federal Laws. <br /> APPLICANTS 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 Received by <br /> REHS: Date Account Account out: Date <br /> COMMENTS: -- <br />