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Date un 5/8/2013 4:52:17PM SAN JC\`UIN COUNTY ENVIRONMENTAL HEA' I DEPARTMENT <br /> Run by T V Report p5011 <br /> Facility Information as of 5/8/2013 Pagel <br /> Rewrd Selection Unions Facility ID FA0003850 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID <br /> OW0002847 New Owner ID <br /> Owner Name M & M BUILDERS SUPPLY INC <br /> Owner DBA M&M BUILDERS SUPPLY INC <br /> Owner Address 8111 W 11TH ST <br /> TRACY, CA 95304 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-835-4172 <br /> Mailing Address PO BOX 1107 <br /> TRACY, CA 95378 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/GFRs ID FA0003850 10,181,483 Site Mitigation Facility <br /> Facility Name M&M BUILDERS SUPPLY INC <br /> Location 8111 W ELEVENTH ST <br /> TRACY, CA 95304 <br /> Phone 209-835-4172 <br /> Mailing Address PO BOX 1107 <br /> TRACY, CA 95378 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN 25014006 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone L <br /> Night Phone y\ <br /> ACCOUNTS RECEIVABLE FILE INFORMATION 0. <br /> Account ID AR0003438 �\1�j New Account ID: <br /> Mail Invoices to Owner �\� ✓ Mail Invoices to: Owner / Facility / Account <br /> Account Name M & M B S SUPPLY INC (Circle One) <br /> Account Balance as of 5/8/2013: 3 .5 <br /> (Circe One) <br /> PrograMElement and Description Record ID Employee ID and Name Status Transfer to Activellnactve <br /> Naw Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO519749 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0511875 EE0000000-HAZ MAT SJC OES Inactive Y N A D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0231530 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0509587 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PRO533972 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,PMS/EMD hourly charges associated with this facility <br /> oractivity will be billed to the Party identified as the OWNER on this formrt I also certify that all operations will be performed in accordance with all applicable Ordinance 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 <br /> /��-,� ��� _/ /�/�Check Number Receiv <br /> REHS: hal"O'wsn Date Account out: Date / l <br /> COMMENTS: <br /> RV 5�201 ► 3 <br />