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Date run 7/17/2014 1:11:50PR SAN JOA��N COUNTY ENVIRONMENTAL HEAL` DEPARTMENT Report*5021 <br /> Run by 4� Pagel <br /> Facility Information as of 7/17/2014 � <br /> Record Selection Criteria: Facility ID FA0010524 <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 : ofd 68,RYI3O <br /> Owner ID OW0008524 Case Number: H08273 New Owner ID <br /> Owner Name YOUNGBLOOD, ROBERT <br /> Owner DBA DYNOMASTER INC {PS2 M(L s na I_nn. <br /> Owner Address 10830 S HARLAN RD <br /> FRENCH CAMP, CA 952319600 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-234-1963 <br /> Mailing Address 10830A S HARLAN RD <br /> FRENCH CAMP, CA 95231-9600 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0010524 10183615 <br /> Facility Name DYNOMASTER INC t T.Psef Yn[t e R j ryv <br /> Location 10830 S HARLAN RD <br /> FRENCH CAMP, CA 95231 <br /> Phone 209-234-1963 x0 <br /> Mailing Address 10830A S HARLAN RD <br /> FRENCH CAMP, CA 95231-9600 <br /> Care of DYNOMASTER INC <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax .23 3q/c3 <br /> APN 19333028 EMail: nea In ma-sler inc•COM <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION // <br /> Contact Name Wnhpr4 Rlr /C(YI E�� YOC1/1Q �rrfine{' <br /> Title �Lp 1 ne rQ <br /> Day Phone oTN�' w-3z(- (9(e <br /> Night Phone e, <br /> ACCOUNTS RECEIVABLE FILE INFORMATION 15 = <br /> AccountlD AR0017524 New Acc <br /> Mail Invoices to Owner Mail Invoices to: owner / :Facility / Account <br /> Account Name YOUNGBLOOD, ROBERT (Circle Ona) <br /> Account Balance as of 7/17/2014: $0.00 <br /> (Circle One) <br /> Transfer to ActiveJlnacNe <br /> PrograMElemenl and Description Record ID Employee ID and Name Status New Owner? Delete <br /> t q7.t <br /> 1920,HMBP-Common Materials PRO512812 EE0008709-JAMIE DE LA ROSA Inactive Y N 1 I D <br /> 2220-SM HW GEN<5 TONS/YR PRO538469 EE0002646-THUY TRAN Inactiv< Y N I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO510524 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO531412 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andor 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 andor Standards and State ander <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: 3 p-0i/u`Lf�9�c'--r--c^_ —/ Date 1 1 P <br /> Program Records to be TRANSFER $25.00= Amount Paid Date / I <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Recei rg�nf <br /> REHS: Date / / Account out: Date_ /fig/ <br /> COMMENTS: <br /> �r- < <� G.(aV.�P< � YQ� (ply <br />