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Date run 2/26/2016 11:06:29AP SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 2/26/2016 <br />Record Selection Criteria: Facility ID FA0009309 <br />OWNER FILE INFORMATION Number of facilities for this owner : 1 <br />Owner ID <br />OW0007309 Case Number: H03024 <br />Owner Name <br />CONCO-WEST, INC. <br />Owner DBA <br />CONCO-WEST INC <br />OwnerAddress <br />322 WETMORE ST <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />MANTECA, CA 95337 <br />Home Phone <br />209-239-2110 <br />Work/Business Phone <br />209-239-2110 <br />Mailing Address <br />PO BOX 1360 <br />Account Balance as of 2/26/2016: $0.00 <br />MANTECA, CA 95336 <br />Care of <br />(Circle One) <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0009309 10182579 <br />Facility Name <br />CONCO-WEST INC <br />Location <br />322 E WETMORE ST <br />Y N A ' _lJ D <br />MANTECA, CA 95337-5741 <br />Phone <br />209-239-2110 x <br />Mailing Address PO BOX 1360 <br />MANTECA, CA 95336 <br />Care of CONCO-WEST, INC. <br />Location Code 04 - MANTECA <br />Bos District 005 - ELLIOTT, BOB <br />APN 22104032 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Make changestcorrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0016309 NewAccount ID: <br />Mail Invoices to Account Mail Invoices to: Owner <br />/ Facility / Account <br />Account Name CARLI STRINGFELLOW <br />(Circle One) <br />Account Balance as of 2/26/2016: $0.00 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status <br />New Owner? Delete <br />1921 - HMBP-Reqular-Primary Location PR0519536 EE0000010 - PETER LOMBARD] Active <br />Y N A ' _lJ D <br />2220 - SM HW GEN <5 TONS/YR PRO539014 EE0009001 -ELENA MANZO Active <br />Y N A I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511597 EE0000000 - HAZ MAT SJC OES Inactive <br />Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0509309 EE0000000 - HAZ MAT SJC OES Inactive <br />Y N A I D <br />4740 - WASTE TIRE SITE - EXEMPT PR0527944 EE0009000 - HARPRIT MATTU Active <br />Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGI PR0533737 Inactive <br />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 spec fic, 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 anclor <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 />L_0 e -rf Z 12)1& AccountDate <br />/- <br />EHD Staff: Date / out: - %145 5. <br />COMMENTS: Q�[�W17u� - Invoice #: <br />�es i 5 <br />PAZ- <br />