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Date run 2/17/2017 8:09:04AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/17/2017 <br />Record Selection Criteria: Facility ID FA0013982 <br />OWNER FILE INFORMATION Number of facilities for this owner : 2 <br />Owner ID <br />OW0011062 <br />Owner Name <br />BRAKE MASTERS OF SACRAMENTO <br />Owner DBA <br />BRAKEMASTERS <br />OwnerAddress <br />6179 E BROADWAY BLVD <br />Phone <br />TUCSON, AZ 85711 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />520-512-0000 <br />Mailing Address <br />6179 E BROADWAY <br />Location Code <br />TUCSON, AZ 85711 <br />Care of <br />005 - ELLIOTT, BOB <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0013982 10184551 <br />Facility Name <br />BRAKE MASTERS #164 <br />Location <br />515 E YOSEMITE BLVD <br />PR0521236 <br />MANTECA, CA 95336 <br />Phone <br />209-239-7400 x <br />Mailing Address <br />6179 E BROADWAY <br />I D <br />TUCSON, AZ 85711 <br />Care of <br />Brake Masters Of Sacramento <br />Location Code <br />04 - MANTECA <br />BOS District <br />005 - ELLIOTT, BOB <br />APN <br />22311022 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0023652 <br />Mail Invoices to Account <br />Account Name BRAKE MASTERS #164 <br />Account Balance as of 2/17/2017: $2,176.00 <br />Prograrrl/Element and Description ( (O l <br />4t2-1Z�- HMBP-Reqular-Primary Location <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION <br />2227 - GEN 5<25 TONS PERMIT <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FI <br />2831 -AST FAC >/= 1,320 - <10 K GAL CUMULATIVE <br />4740 - WASTE TIRE SITE - EXEMPT <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGI <br />Make changes/corrections 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 />Mail Invoices to <br />New Acco u nt I D: : <br />Owner / Facility <br />(Circle One) <br />Account <br />(Circle One) <br />Transfer to Active/Inactve <br />Record ID <br />Employee ID and Name <br />Status <br />New Owner? <br />Delete <br />PR0521236 <br />EE0000009 - NICHOLAS LOEHRER <br />Active <br />Y <br />N <br />A <br />I D <br />PR0518848 <br />EE0000000 - HAZ MAT SJC OES <br />Inactive <br />Y <br />N <br />A <br />I D <br />PR0518575 <br />EE0009001 - ELENA MANZO <br />Active <br />Y <br />N <br />A <br />I D <br />PR0518576 <br />EE0002670 - MUNIAPPA NAIDU <br />InactivE <br />Y <br />N <br />A <br />I D <br />PR0541624 <br />EE0009001 - ELENA MANZO <br />Active <br />Y <br />N <br />A <br />I D <br />PR0523922 <br />EE5555555 - Garrett Alias -Backus <br />InactivE <br />Y <br />N <br />A <br />I D <br />PR0532240 <br />InactivE <br />Y <br />N <br />A <br />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 and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: * $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Type Che k Number Received <br />EHD Staff: Date h //�— Account out: 11,46T Date z / /47 <br />COMMENTS: G r G� c ` <br />Invoice #: <br />