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Date run 7/19/2013 10:39:10AI SAN JO AN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/19/2013 <br /> Record Selection Criteria: Facility ID FA0021650 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0017813 New Owner ID <br /> Owner Name THRASHER, DERONE <br /> Owner DBA <br /> Owner Address 2295 S MACARTHUR DR <br /> TRACY, CA 95376 <br /> Home Phone 800-571-6143 <br /> Work/Business Phone 209-969-8163 <br /> Mailing Address 2295 S MACARTHUR DR <br /> TRACY, CA 95376 <br /> Care of THRASHER, DERONE <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID/CERS ID FA0021650 <br /> Facility Name THRASHER, DERONE <br /> Location 2295 S MACARTHUR DR <br /> TRACY, CA 95376 <br /> Phone 800-571-6143 <br /> Mailing Address 2295 S MACARTHUR DR <br /> TRACY, CA 95376 <br /> Care of THRASHER, DERONE <br /> Location Code 03-TRACY Alt Phone <br /> BOS District 005- ELLIOTT, BOB Fax <br /> APN 24614002 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name THRASHER, DERONE <br /> Title <br /> Day Phone 800-571-6143 <br /> Night Phone 209-969-8163 Cell <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0039267 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name TETRA TECH (Circle one) <br /> Account Balance as of 7/19/2013: $-250.00 <br /> (Circle One) <br /> Transfer to ActiveAnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0537604 EE0001699-JOHNNY YOAKUM Active 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 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 withal]applicable Ordinance Codes and/or Standards and State andlor <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 /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />