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Date run 3/11/2013 1:16:19PI1 SAN JOIN COUNTY ENVIRONMENTAL HEA*DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/11/2013 <br /> Record Selection Criteria: Facility ID FA0010004 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN 1 Fed Tax ID <br /> Owner ID OW0008004 Case Number: H06205 New Owner ID <br /> Owner Name DAN CORBOFF <br /> Owner DBA DAN'S DISTRIBUTING CO INC <br /> Owner Address 933 E YOSEMITE AVE <br /> MANTECA, CA 95336 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-883-4149 <br /> Mailing Address 801 S 9TH ST <br /> MODESTO, CA 95351-4012 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010004 <br /> Facility Name DANS DISTRIBUTING CO INC <br /> Location 933 E YOSEMITE AVE <br /> MANTECA, CA 95336 <br /> Phone 209-823-6867 x0 <br /> Mailing Address 801 S 9TH ST <br /> MODESTO, CA 95351-4012 <br /> Care of <br /> Location Code 04 - MANTECA Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 22324007 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account lD AR0017004 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name DANS DISTRIBUTING CO INC (Circle One) <br /> Account Balance as of 311112013: $350.00 <br /> (Circle One) <br /> Transfer to Activellractve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> \1921 HMBP-Regular-Primary.Location PRO520350 EE0002474-MICHAEL PARISSI Active Y N A U, D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOI`PR0512292 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARCPR0510004 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0532598 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSIEHD 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 andlor Standards and Stale ansor <br /> Federal Laws, <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Ty e Check Number Receiv d <br /> Date '2,} ] 1�_ Account out: Date 1 1 <br /> owls: <br /> 31 s1r3 <br />