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Daferun 2!2312012 11;37:45Ai <br /> SANK UIN COUNTY ENVIRONMENTAL HEA. DEPARTMENT Report45021 !� <br /> Run by � Pagel '1 <br /> •�'`� Facility Information as of 2/23/2012 <br /> Record Selection Criteria: Facility ID FA0021021 <br /> F s Make changeslcorrections in RED ink, �[j) <br /> INFORMATION CHANGE(date) 3 <br /> } OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION `^ <br /> SSN 1 Fed Tax ID , <br /> Owner ID OW0017300-' New Owner ID <br /> Owner Name MEDINA, LUIS H <br /> Owner DBA <br /> Owner Address 11530 MOUNTAIN VIEW RD <br /> TRACY, CA 95376 <br /> Home Phone 209-836-0682 <br /> 'i <br /> Work/Business Phone 510-760-9137 <br /> Mailing Address 11530 MOUNTAIN VIEW RD <br /> TRACY, CA 95376 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> i <br /> Facility ID FA0021.021 <br /> Facility Name COLOMEX MOBILE FRAME& BODY <br /> Location 23731 S CHRISMAN RD <br /> TRACY, CA 95304 <br /> Phone 510-760-9137 i <br /> Mailing Address 23731'S CHRISMAN RD <br /> TRACY, CA 95304 <br /> Care of MEDINA, LUIS H <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 005-ORNELLAS, LEROY Fax <br /> APN 25014013 Entail: <br /> a <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name LUIS H MEDINA <br /> Title OWNER <br /> Day Phone 510-760-9137 <br /> Night Phone 209-836-0682 <br /> I ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0037834 New Account ID: I <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility 1 Account <br /> Account Name COLOMEX MOBILE FRAME & BODY (CirdeOne) <br /> Account Balance as of 2123/2012: $262.00 <br /> - (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete r <br /> 2220-SM HW GEN<5 TONSIYR PRO536608 EE0002646-THUY TRAN Active Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPR0536609 Active Y N A N D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHS1EHb hourly charges associated with this gg- <br /> facility or activitywill 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 Ordinace Codes and/or Standards and q <br /> State and/or Federal Laws. I` <br /> APPLICANT'S SIGNATURE: Date I` I <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date 1 I li <br /> Payment Type Check Number Received by <br /> REHS: ,ll/ Date 08/22 1 ).Z Account out: Date :?2 <br />+ <br /> COMMENTS: <br /> CCUJJ <br /> b <br /> jIleh-envlenvisioMreports15021.rpt <br />