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Date run ' 4/8/2013 4:22:15PM SAN J04WIN COUNTY ENVIRONMENTAL HEALS dDEPARTMENT Report#5021 <br /> Run by I Page <br /> Facility Information as of 4/8/2013 <br /> Record Selection Criteria: Facility ID FA0005302 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0003473 New Owner ID <br /> Owner Name SPRECKELS SUGAR CO <br /> Owner DBA SPRECKELS SUGAR COMPANY <br /> Owner Address 20500 HOLLY DR <br /> TRACY, CA 953041649 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-835-3217 <br /> Mailing Address PO BOX 68 <br /> MENDOTA, CA 93640 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility lD/CERS ID FA0005302 10,181,793 <br /> Facility Name SPRECKELS SUGAR COMPANY <br /> Location 20500 HOLLY DR <br /> TRACY, CA 95304 <br /> Phone 209-835-3217 <br /> Mailing Address PO BOX 68 <br /> MENDOTA, CA 93640 <br /> Care of <br /> Location Code 99 - UNINCORPORATED,11 Alt Phone <br /> Bos District 005 -ORNELLAS, LEROY Fax <br /> APN 21216010 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 AR0005764 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name SPRECKELS SUGAR COMPANY (C1rcle One) <br /> Account Balance as of 4/8/2013: $608.00 <br /> (Circle One) <br /> Transfer to Active/Inacive <br /> ProgiaMElement and Description Record ID Employee ID and Name Status New Omer? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0519583 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO513793 EE0002646-THUY TRAN Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0511655 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2361 -UST FACILITY PRO502021 EE0002646-THUY TRAN Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0507590 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PRO515794 EE0002646-THUY TRAN Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0531511 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,PHS/EHD hourly charges associated with this facility <br /> oradivity will be billed to the partyidentdied as the OWNER on this form Ialso certify that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and State endor <br /> Federal Laws. ,1Ar <br /> APPLICANT'S SIGNATURE: /ecse— 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 />