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Date gun 4/8/2014 9:24:30AM SAN JOAW COUNTY ENVIRONMENTAL HEAL EPARTMENT Report#5021 <br /> Run by t Paget <br /> Facility Information as of 4/8/2014 <br /> Record Selection Catena: Facility ID FA0012478 <br /> Make changeslcorrections 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 <br /> Owner ID OW0009681 New Owner ID <br /> Owner Name SMITH, LLOYD <br /> Owner DBA LS EXPEDITERS <br /> Owner Address 1205 MOFFAT <br /> MANTECA, CA 95336 <br /> Home Phone Not Specified <br /> Work/Business Phone 800-730-0606 <br /> Mailing Address PO BOX 31985 <br /> STOCKTON, CA 95213-1985 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0012478 10,184,289 <br /> Facility Name LS EXPEDITERS <br /> Location 1205 MOFFAT BLVD <br /> MANTECA, CA 95336 <br /> Phone 800-730-0606 x0 <br /> Mailing Address PO BOX 31985 <br /> STOCKTON, CA 95213-1985 <br /> Care of <br /> Location Code 04-MANTECA Alt Phone <br /> SOS District 005- ELLIOTT, BOB Fax <br /> APN 22121005 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0020342 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name SMITH, LLOYD (Circle One) <br /> Account Balance as of 4/8/2014: $#40.0 r Jf <br /> (Circe One) <br /> Transfer to Actheflnacwe <br /> Program/Element and Description Record ID Employee ID and Name Status New OWneO Delete <br /> 1921 -HMBP-Regular-Primary Location PRO520937 EE0002474-MICHAEL PARISSI Active Y N A OI D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO516141 EE0000000-HAZ MAT SJC DES Inactive Y N A 1 D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO516142 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO535980 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,opendw or agent of same,acknowledge that all site,andtor project specific,PHS/EHD hourly charges associated with this reality <br /> or activity will be billed to the party identified as the OWNER on thisform. I also certify that all operations will oe performed in accordance with all applicable Ordinance Codes andfor Standards and State and'or <br /> Federal Laws. .o,. .//�j <br /> APPLICANTS SIGNATURE: �I tee- 1 j l� Date I I <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 Reci by <br /> REHS: / '�� Date / /p� Account out: _ Date <br /> COMMENTS: <br /> SCS f�11_ll.r( '-/,,�ly7Kp-�(1yJ/ �6r �eL�fv 2 G/aSc..� <br />