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Date ruo 4/23/2013 9:39:01AN SAN JOE JIN COUNTY ENVIRONMENTAL HEAL�DEPARTMENT Report#5021 <br /> Run by +� Pagel <br /> Facility Information as of 4/23/2013 <br /> Record Selection Criteria: Facility ID FA0009948 <br /> Make changes/corrections in RED ink. <br /> /1 INFORMATION CHANGE(date) <br /> ,[AX\// OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0007948 Case Number: H05977 New Owner ID <br /> Owner Name A&A ROSSI HAY SERVICE <br /> Owner DBA <br /> Owner Address-611 NAIFNPL�AY <br /> MANTECA, CA 95336 <br /> Home Phone 209-609-6954 <br /> Work/Business Phone 209-823-3965 <br /> Mailing Address PO BOX 332 <br /> MANTECA, CA 95336 <br /> Care of A&A ROSSI HAY SERVICE <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0009948 10,183,053 <br /> Facility Name A&A ROSSI HAY SERVICE <br /> Location �/r?,fy+ <br /> MANTECA, CA 95336 �t <br /> Phone 209-823-3965 <br /> Mailing Address PO BOX 332 <br /> MANTECA, CA 95336 <br /> Care of <br /> Location Code 04 - MANTECA Alt Phone <br /> BOS District 003- BESTOLARI DES Fax ��-,3 1-', <br /> APN 19816021 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016948 NewAccount ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name A&A ROSSI HAY SERVICE (Circle One) <br /> Account Balance as of 4/23/2013: $6,566.10 <br /> (Circle One) <br /> Transfer to Active/Iname <br /> Progra"Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO519980 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO514106 EE0002646-THUY TRAN Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512236 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PRO509948 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2832-AST FAC 10 K-</=100 K GAL CUMULATIVEPRO515679 EE0002646-THUY TRAN Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO535794 EE0007379-AMANDA BOERTIEN Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0531871 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the parry identified as Ne OWNER on this formi also certify that all operations will be performed in accordance with all applicable Ortlinance Codes andor Standards and State ander <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 b <br /> REHS �� Date /2-'�?,_/ _ Account out: Date <br /> COMMENTS: / 6A6A ro�` <br /> VA.Vr^rte �i v1� LA `I/1p��[.rl'�tS' <br />