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Rate run 8/26/2014 8:51:30AA SAN JO, Report#5021 <br /> JIN COUNTY ENVIRONMENTAL HEALJDEPARTMENT <br /> Run by Pagel <br /> Facility Information as of 8/26/2014 <br /> Record Selection Criteria: Facility ID FA0010986 <br /> Make changes/corrections in RED ink. /p q <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN/Fed Tax ID : <br /> Owner ID OW0012761 New Owner ID <br /> Owner Name Oldcastle Precast, Inc <br /> Owner DBA <br /> Owner Address 1002 15TH ST <br /> AUBURN, WA 98001 <br /> Home Phone 253-833-2777 <br /> Work/Business Phone 253 <br /> Mailing Address PO Box 608 <br /> Auburn, WA 98071 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0010986 10184013 <br /> Facility Name Oldcastle Precast, Inc. <br /> Location 15540 S MCKINLEY RD <br /> Lathrop, CA 95330 <br /> Phone 209-858-0093 x <br /> Mailing Address PO Box 727 <br /> Pleasanton, CA 94566 <br /> Care of Oldcastle Precast, Inc <br /> Location Code Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 19806010 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name ERNEST JORDAN <br /> Title PLANT MANAGER <br /> Day Phone 209-858-0225 <br /> Night Phone 209-495-0796 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017986 New Account ID: <br /> Mail Invoices to Facility d r � �, Mail Invoices to: Owner / Facility / Account <br /> Account Name Oldcastl t, Inc. (Circle One) <br /> Account Balance as of 8/26/2014: $483.00 S 2t/f <br /> (Circle One) <br /> Transfer to Aclivednadve <br /> PmgramrElement and Description .Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO513274 EE0002474-MICHAEL PARISSI Active Y N A D <br /> 2220-SM HW GEN<5 TONSNR PR0528654 EE0002646-THUY TRAN Active Y -N A D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510986 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC <1.320 GAL PR0528653 EE0002646-THUY TRAN Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533334 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specilc,PHS/EHD 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 andor <br /> Federal Laws. <br /> APPLICANTS 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 — Check Number Receiv <br /> RENS: . Y/it/I...rrci Date K / / Account out: Date R/&774— <br /> COMMENTS: <br />