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Date run 11/9/2018 10:17:09Af SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 11/9/2018 <br /> Record Selection Criteria: Facility ID FA0011059 <br /> Make changes/corrections in RED ink. / c/ <br /> INFORMATION CHANGE(date) ?L1 <br /> �f <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br /> Owner ID OW0009059 Case Number: H09227 New Owner ID : <br /> Owner Name e 1►ss� 4— ,J 4 , L.L C. <br /> Owner DBA 141 �LCVAbV(V Q <br /> OwnerAddress 25451 S MOUNTAIN HOUSE PKWYy�, Lhn, CT fat-911 <br /> TRACY, CA 953779717 <br /> Home Phone 289 547 3040 <br /> Work/Business Phone <br /> Mailing Address PO BOX 1387 <br /> MANTECA, CA 95336-1147 WLi— b(a9�1 <br /> Care of A Isx x 11°►I dor] A t c kod 'W Q'f SS <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0011059 10184073 <br /> Facility Name AACid 1555 ^4' LLL <br /> Location 25451 S MOUNTAIN HOUSE PKWY <br /> TRACY, CA 95377 <br /> Phone _ _ toy 43-a Do <br /> Mailing Address ,P1D$-)X&5Q, QSHSI s Mo,,O4,/n Hey5e ewot/ <br /> P 1 —,rv-*LV, G5 q43?7 <br /> Care of UNITED FACII (TIES INC <br /> Location Code Alt Phone <br /> BOS District 005 - Fax <br /> APN 20944013 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 AR0018059 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name (Circle One) <br /> Account Balance as of 11/9/2018 -392 10 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0520642 EE0000009-NICHOLAS LOEHRER Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513347 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0511059 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0535220 EE0002620-ALFONSO ARAMBULA Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0531524 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 ancVor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date <br /> Water System to be FERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: Date Account out: Date <br /> COMMENTS: <br /> Invoice <br />