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Date run 8/18/2014 2:11:26PK SAN X IUIN COUNTY ENVIRONMENTAL HE/ H DEPARTMENT Report#5021 <br /> R.by <br /> Pagel <br /> y Facility Information as of 8/18/2014 <br /> Record Selection Criteria: Facility ID FA0012412 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner lD OW0009624 New Owner ID <br /> Owner Name DIVERSIFIED CONSTRUCTION SERV <br /> Owner DBA DIVERSIFIED CONSTRUCTION SERVI <br /> Owner Address 5565 S EL DORADO <br /> FRENCH CAMP, CA 95231 <br /> Home Phone Not Specified <br /> Work/Business Phone 916-939-3989 <br /> Mailing Address 5565 S ELDORADO ST <br /> FRENCH CAMP, CA 95231 <br /> Care of JONES, STEVEN M <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0012412 10184235 <br /> Facility Name DIVERSIFIED CONSTRUCTION SERVICES <br /> Location 5565 S EL DORADO ST <br /> FRENCH CAMP, CA 95231 <br /> Phone 209-982-5000 <br /> Mailing Address 5565 S ELDORADO ST <br /> FRENCH CAMP, CA 95231 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOIS District 001 -VILLAPUDUA Fax <br /> APN 19302052 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 AR0020269 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name DIVERSIFIED CONSTRUCTION SERVICES (Circle 0.) <br /> Account Balance as of 8/18/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inectve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO520701 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0515995 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO515996 EE0000000-HAZ MAT SJC OES InactivE Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0515997 EE0009999-SITE UNASSIGNED InactivE Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO528786 EE0001421 -STACY RIVERA InactivE Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO535799 EE0009000-HARPRIT MATTU Active Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532354 Inactivc Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,endor project spec,PHSIEHD hourly charges assodated with this faolity <br /> or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will toe performed in accordance with all applicable Ordinance Codes andor Standards and State ardor <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 />