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Date run 5113!2013 1:51:55Pk SAN JC 'JIN COUNTY ENVIRONMENTAL.I{EA 1 DEPARTMENT RepWill <br /> Run by _W11" Pagel <br /> Facility Information as of 5/13/2013 <br /> Record Selection Criteria. Facility ID FR0019720 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) ` <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0016177 New Owner ID <br /> Owner Name GLENN MILLER <br /> Owner DBA LAM SPICE CO INC <br /> Owner Address 824 S CENTER ST <br /> STOCKTON, CA 95206 1 <br /> Home Phone Not Specified 6 t1 � <br /> Work/Business Phone 209-586=9569- ' <br /> Mailing Address PO BOX 640 <br /> MI WUK VILLAGE, CA 95346 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility IDICERS ID FA0019720 10,187,361 <br /> Facility Name LAM SPICE CO INC <br /> Location 824 S CENTER ST <br /> STOCKTON, CA 95206 <br /> Phone 209-58G=9569-x@ `) > �-,.* C 9 S <br /> Mailing Address PO BOX 640 <br /> MI WUK VILLAGE, CA 95346 <br /> Care of <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 14714007 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 AR0035082 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner ! Facility ! Account <br /> Account Name GLENN MILLER (Circle One) <br /> Account Balance as of 5/13/2011 $0.00 <br /> (Circle One) <br /> Transfer to Acliveflnaclve <br /> PrograrNElemenl and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0529883 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0534184 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andror 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 andtor Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE Date _1_/ <br /> Program Records to be TRANSFERED "$25.00= Amount Paid Date I I <br /> Water System to be TRANSFERED: Amount Paid Date-/-I <br /> Payment Typp,- Check Number Received by _ <br /> RENS: Date C �C" ! Account out: Date ! Z�1 13 <br /> COMMENTS <br /> (,v' Ir <br />