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Date run 2/20/2013 11:14:12AI SAN JOWIN COUNTY ENVIRONMENTAL HEAiP DEPARTMENT Report#5021 <br /> Run by w Pagel <br /> Facility Information as of 2120120 3 <br /> Recoid Selection Criteria: Facility ID FA0010004 <br /> Make changeslcorrections In RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSNI Fed Tax ID <br /> Owner ID OW0008004 Case Number: H06205 New Owner ID <br /> Owner Name DAN COR13OFF <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 933 E YOSEMITE AVE xbI _ cS <br /> MANTECA, CA 95336 <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 933 E YOSEMITE AVE gDJ `j <br /> MANTECA, CA 95336 es., d 9S 1Z <br /> Care of <br /> Location Code 04- MANTECA Alt Phone <br /> BOS District 003- BESTOLARIDES Fax <br /> APN 22324007 EMajl: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017004 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner 1 Facility I Account <br /> Account Name DAN CORBOFF (Circle One) <br /> Account Balance as of 2/20/2013: $350.00 <br /> (Circle One) <br /> Transfer to Active(Inactve <br /> ramlElement and Description Record ID Employee ID and Name Status New CwneR Delete <br /> 1921 -)HMBP-Regular-Primary Location PRO520350 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> N,2224-o-'HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512292 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0510004 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PRO532598 Inactive Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andtor 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 811 operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State andfor <br /> Federal Laws. , <br /> APPLICANT'S SIGNATURE: `L Date I I <br /> Program Records to be TRANSFERED: $25.00= Amount Paid Date I 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received.by <br /> REHS: Date 1 ! Account out: Date ;2- ! 1 43 <br /> COMMENTS: <br /> QA 2 z-� �� <br />