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Catchall 2/27/2014 3:35:19Pt` SAN JO#N COUNTY ENVIRONMENTAL HEA EPARTMENT <br /> Report#5021 <br /> Run by � Pagel <br /> Facility Information as of 2/27/2014 <br /> Record Selectio Cnbma: Facility ID FA0012478 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSNI 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 lD/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 /> BOS 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 2/27/2014: $410.00 <br /> (Circe One) <br /> Transfer to ActiveAnactve <br /> Program/Element and Description Record 10 Employee ID and Name Status New Omen Delete <br /> 1921 -HMBP-Regular-Primary Location PRO620937 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO516141 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO516142 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0535980 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anryor project specific,PHSIEHO hourly charges associated with this facility <br /> or activity will be billed to the party identifietl as the OWNER on this forml also certify that all operations will be performed in accordance with all applicable Ordinance Codes andror standards and State ands <br /> Federal Laws. ' <br /> APPLICANTS SIGNATURE: — LJ V/�e� 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 /_I_ Account out: Date <br /> COMMENTS: <br /> V lam'✓ —rvl{(yV••</_Jir(tl'�n-�J/�//. <br />