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Date run 1/28/2013 9:47:41Ah SAN JOIIIIIIIIIUIN COUNTY ENVIRONMENTAL BEA,lltIW DEPARTMENT Repoli#5021 <br /> Pagel <br /> Run by <br /> Facility Information as of 1/28/2013 <br /> Record Selection Criteria: Facility ID FA0010986 <br /> Make changesicorrections I <br /> INFORMATION C t <br /> OWNERSHIP CHAIE(dat!-7 <br /> OWNER FILE INFORMATION SSN/Fed Tax ID : <br /> Owner ID OW0012761 New Owner ID <br /> Owner Name US CONCRETE INC <br /> Owner DBA US CONCRETE PRECAST GROUP LZ>(2A-57-L - P/?PCAcST T <br /> Owner Address 3049 INDEPENDENCE DR STE —�O BOX (9095 <br /> LIVERMORE, CA 94551 AUE3aGRA/ A 9807/ <br /> Home Phone Not Specified <br /> Work/Business Phone 713-499-6201 $33 - 27-7 -7 <br /> Mailing Address 3049 INDEPENDENCE DR STE A PO f3 C)X (n 08 <br /> LIVERMORE, CA 94551 fH/8[[RN LUA 9cF07/ <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010986 <br /> Facility Name US CONCRETE PRECAST CROUP O LbCR-� 7Y€. ER-L T <br /> Location 15540 S MCKINLEY RD <br /> LATHROP, CA 95330 <br /> Phone 209-858-0093 <br /> Mailing Address 3049 INDEPENDENCE DR STE A 5;540 C . C tV - A• <br /> LIVERMORE, CA 94551 ( A7,q;20)0 Cf4 °l6-5 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District 003- BESTOLARIDES Fax <br /> APN 19806010 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name l?Af R-IQ E5—r,—M 09—r->AI J <br /> D <br /> Title r L-AA f-F MFFIV 4 E� EY` <br /> Day Phone 2.0 q — IQ E3 r�-— <br /> Night Phone 2094495 ' 079( <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017986 NewAccount ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner I Facility / Account <br /> Account Name US CONCRETE PRECAST CROUP (Circle One) <br /> Account Balance as of 1/28/2013: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactse <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 HMBP-Regular-Primary Location PR0513274 EE0002474-MICHAEL PARISSI Active rp� N A I D <br /> -SM HW GEN<5 TONS/YR PRO528654 EE0002646-THUY TRAN Active YJ N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PRO510986 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PRO528653 EE0002646-THUY TRAN Active,Exempt © N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCFLPR0533334 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on his form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws. <br /> C,10 q) '/0 -3,3/-7-2— <br /> APPLICANTS SIGNATURE: �� -� �A �GC-CC�uO� Ma/e-9Z#1 Date <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date I / <br /> Payment Type eck Number Recei e y 3 ��l <br /> REHS: Date / 1028" / Account out: Date o / / ` <br /> kr <br /> COMMENTS: I` <br /> V IN <br /> f/I <br />