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Date run 11/9/2015 8:38:36AIV SAN A UIN COUNTY ENVIRONMENTAL HEA& DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 11/9/2015 <br /> Record Selection Criteria: Facility ID FA0011278 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN 1 Fed Tax ID <br /> Owner ID OW0009278 New Owner ID <br /> Owner Name AMBERLAND COMPOSITES LLC <br /> Owner DBA AMBERLAND COMPOSITES LLC <br /> Owner-Address 3632 DUCK CREEK DR <br /> STOCKTON, CA 95215 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-460-1600 <br /> Mailing Address 3632 DUCK CREEK DR STE F <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID J CERS ID FA0011278 10184137 <br /> Facility Name AMBERLAND COMPOSITES LLC <br /> Location 3632 DUCK CREEK DR BLDG F <br /> STOCKTON, CA 95215 <br /> Phone 209-460-1600 x0 <br /> Mailing Address 3632 DUCK CREEK DR STE F <br /> STOCKTON, CA 95215 <br /> Care of Komet Choopratheep <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 17331015 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 AR0018278 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility 1 Account <br /> Account Name AMBERLAND COMPOSITES LLC (Circle One) <br /> Account Balance as of 11/g/2015: $0.00 <br /> (Circle One) <br /> Transfer to Activednacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO513566 EE0000009-NICHOLAS LOEHRER Active Y N A I D <br /> 2220-SM HW GEN<5 TONSJYR PR0529343 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0511278 EE0fl00000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0532542 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator cr agent of same,acknowledge that all site,and project specific,PHSfEHD 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 anti Standards and State and+or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date 1 ! <br /> Water System to be TRANSFERED: Amount Paid Date ! 1 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date J J Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />