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lwe run ` 2/19/2016 10:31:36AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 2/19/2016 Record Selection Criteria: Facility ID FA0009519 OWNER FILE INFORMATION Number of facilities for this owner: 1 Owner ID OW0007519 Case Number: H04697 Owner Name HORMEL FOOM CORP 1404 S FRESNO AVE Owner DBA �. Phone Owner Address 1 SMT ' MET PL 1301 Dove St., Suite 940 EE0000000 - HAZ MAT SJC OES AUSTIN, N 55912 Care of Home Phone 507-437-5, 01 - STOCKTON Work/Business Phone 507-43761 APN Mailing Address 1 HORMEL PL Inactive Y N AUN, MN 55912 PR0531606 Care of HO MEL FOODS CORPORATION FACILITY FILE INFORMATION Facility ID / CERS ID FA0009519 10182749 Facility Name CRM - Crum Rubber Manufacturers Location 1404 S FRESNO AVE PR0513881 STOCKTON, CA 95206 Phone 209-943-5411 x Mailing Address 1301 Dove St., Suite 940 EE0000000 - HAZ MAT SJC OES NEWPORT BEACH, CA 92660 Care of Steve Krauss Location Code 01 - STOCKTON BOS District 001 - VILLAPUDUA, CARLOS APN 16337018 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN/ Fed Tax ID New Owner ID CAL IZ7 Alt Phone Fax EMail : Account ID AR0016519 New Account ID: Mail Invoices to Account Mail Invoices to: Owner / Account Name CRM CFun1-Rubber_Manufacturers L . Account Balance as of 2/19/20 6: $518.00 _-, ca6�J Program/Element and Description Record ID Employee ID and Name Status Facility / Account (Circle One) Transfer to New Owner? 1921 - HMBP-Reqular-Primary Location PR0519695 EE0009817 - ROBERT LOPEZ Active Y N 2220 - SM HW GEN <5 TONS/YR PR0513881 EE0001421 -STACY RIVERA Active Y N 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PRO511807 EE0000000 - HAZ MAT SJC OES Inactive Y N 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509519 EE0000000 - HAZ MAT SJC OES Inactive Y N 2840 - AST EXEMPT FAC < 1,320 GAL PR0516366 EE0001421 - STACY RIVERA Inactive Y N ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0531606 Inactive Y N (Circle One) Active/Inactve Delete A�D A D A I D A I D A I D A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility 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 and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: * $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received by EHD Staff: ` n Date Z / Cf Account out: Date Z/ ;? -4p / 14" COMMS TS: (� � Invoice #: