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Dale run 2/13/2015 10:55:03AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Report#5021 <br /> Pagel <br /> Run by Facility Information as of 2/13/2015 <br /> Record Selection Criteria: Facility ID FA0016764 <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 OW0013605 New Owner ID <br /> Owner Name IAN KOETSIER <br /> Owner DBA IAN KOETSIER <br /> Owner Address 214 4:7 6 ` `TEG A REI <br /> - <br /> n_e—nco&7 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 914 4.;E 6 P 4AN:FEC-A-79 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0016764 10185371 <br /> Facility Name IAN KOETSIER <br /> Location 21447 S MANTECA RD <br /> MANTECA. CA 95337 <br /> Phone 209-239-3783 x0 <br /> Mailing Address 2444:7 8 -A A -- D C. r`-i r-/` <br /> JCS AJ �20 — <br /> Care of <br /> Location Code Alt Phone <br /> BOIS District Fax <br /> APN 22610008 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 AR0029646 / New Account ID: <br /> Mail Invoices to Owner 7- Mail Invoices to: Owner / Facility / Account <br /> Account Name IAN KOETSIER (CinceOne) <br /> Account Balance as of 2/13/2015: $107.00 <br /> (Circe One) <br /> Transfer to Aclive/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owne? Delete <br /> 1958-HM-Fane Operations PRO524949 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2221 -USED OIL ONLY-<5 TONS/YR PR0538512 EE0009001 -ELENA MANZO Active Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO530709 EE0002670-MUNIAPPA NAIDU Inactive Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532519 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all eite,endor project specific,PHS/EHD hourly charges associated with Nis facility <br /> or activity will be billecl 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 andor Standards end State andor <br /> Federal L. 4.M D. <br /> APPLICANTS SIGNATURE: /r`AIL 1. 1'--TLtLJ Date CP- / Imo/ �S <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 / /itt� <br /> COMMENTS: <br />