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Date run 10!23/2013 2:49:41P SAN JOJWIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run b, Pagel <br /> Facility Information as of 10/23/2013 <br /> Record Selection Criteria: Facility ID FA0019667 <br /> Make changes/corrections In RED ink. <br /> INFORMATION CHANGE(date) '?1 1 -t�- <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0016124 New Owner ID <br /> Owner Name WALT OTT <br /> Owner DBA PERFORMANCE MACHINE <br /> Owner Address 11667 PALM LN <br /> MANTECA, CA 95336 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-484-7987 <br /> Mailing Address 11667 PALM LN UNIT F <br /> MANTECA, CA 95336 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0019667 10,187,295 <br /> Facility Name PERFORMANCE MACHINE <br /> Location 11667 PALM LN UNIT <br /> MANTECA, CA 95336 <br /> Phone 209-239-2000 x0 <br /> Mailing Address 11667 PALM LN UNIT F <br /> MANTECA, CA 95336 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District 005- ELLIOTT, BOB Fax <br /> APN 22809005 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 AR0035029 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name WALT OTT (Circle One) <br /> Account Balance as of 10/23/2013: $2,285.00 <br /> (Circle One) <br /> Transfer to Active1naclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? ^Delete <br /> 1921 -HMBP-Regular-Primary Location PR0529830 EE0002474-MICHAEL PARISSI Active Y N A l I) D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531683 Inactive Y N A 'I' D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor 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(cr 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 Recei <br /> REHS: Date 1('L/ 1°1 /�� Account out: Date <br /> COMMENTS: <br />