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Date run 8/13/2015 3:03:04PR SAN J(&UIN COUNTY ENVIRONMENTAL HEfH DEPARTMENT Report 95021 <br /> Run by Pagel <br /> Facility Information as of 8/13/2 5 <br /> Record Selection Criteria: Facility ID FA0010776 <br /> Make changes/corrections 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 OW0008776 Case Number: H08722 New Owner ID <br /> Owner Name MAURICIO URTEAGA <br /> Owner DBA J&M TRANSMISSION INC <br /> Owner Address 7944 W 11TH ST <br /> TRACY, CA 95304 <br /> Home Phone 209-833-1265 <br /> Work/Business Phone 209-833-7955 <br /> Mailing Address 7944 W 11TH ST#F <br /> TRACY, CA 95304 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0010776 10183809 <br /> Facility Name J&M TRANSMISSION INC <br /> Location 7944 W ELEVENTH ST F <br /> TRACY, CA 953049303 <br /> Phone 209-833-1265 <br /> Mailing Address 7944 W 11TH ST#F <br /> TRACY, CA 95304 <br /> Care of <br /> Location Code 99 - UNINCORPORATED d Alt Phone <br /> BOS District 005- ELLIOTT, BOB Fax <br /> APN 25015002 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 AR0017776 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name J&M TRANSMISSION INC (Circle One) <br /> Account Balance as of 8/13/2015: $585.00 <br /> (Circle One) <br /> Transfer to Activeflnacive <br /> Progranv Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0520484 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0514413 EE0002646-THUY TRAN Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513064 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO510776 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532344 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anNor project specific,PHSIEHD hourly charges associated with this facility <br /> or adivitywill 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 andfor Standards and Stale andfor <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 Received by <br /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: Invoice#: <br />