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Date run ' 2/20/2014 4:39:22PR SAN J , IN COUNTY ENVIRONMENTAL HEAW DEPARTMENT Report#5021 <br /> Run by � Pagel <br /> Facility Information as of 2/20/2014 <br /> Record Selection Criteria: Facility ID FA0012478 <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 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 2098 75 60Y f( <br /> MANTECA, CA 95336 5tD rl <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 2098 ox 31985 <br /> MANTECA, CA 95336 U&D r) 5 <br /> Care of <br /> Location Code 04- MANTECA Alt Phone <br /> BOB 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 2/20/2014: $410.00 <br /> (Circle One) <br /> Transfer to ActiviOnacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO520937 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0516141 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0516142 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,operator or agent of same,acknowledge that all site,andor project spec,PHS/EHO hourly charges associated with this facility <br /> of activity will be billed to the party identified as the OWNER on this form Ialso certify that all operations will be performed in accordance with all applicable Ordinanoe Codes and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S 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 Received by <br /> REHS: Date_/ /_ Account out: _ Date Z /2-* <br /> COMMENTS: <br />