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Date run 12/11/2012 8:31:05A SAN JCjWIN COUNTY ENVIRONMENTAL HEA*DEPARTMENT Reporta5021 <br /> Run by Pagel <br /> Facility Information as of 12/11/2012 <br /> Record Selection Criteria: Facility ID FA0013672 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) 1 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0010781 New Owner ID <br /> Owner Name MINOR, GIL <br /> Owner DBA OWENS AND MINOR WEST <br /> Owner Address 6150 LAS POSITAS RD <br /> LIVERMORE, CA 94550 <br /> Home Phone Not Specified <br /> Work/Business Phone 800-488-8850 <br /> Mailing Address 6150 IAS POSITAS RD <br /> LIVERMORE, CA 94550 <br /> Care of GIL MINOR <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013672 <br /> Facility Name OWENS & MINOR <br /> Location 17720 W SHIDELER PARK <br /> LATHROP, CA 95330 <br /> Phone 209-858-4001 <br /> Mailing Address 17720 W SHIDELER PARK <br /> LATHROP, CA 95330 <br /> Care of GIL MINOR <br /> Location Code 07-LATHROP Alt Phone <br /> SOS District Fax <br /> APN 19823015 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022829 New Account ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name OWENS & MINOR (Circle One) <br /> Account Balance as of 12/11/2012: $0.00 <br /> (Circle One) <br /> Transfer to ActiveMaclve <br /> �ggram/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> //,14141 HMBP-Regular-Primary Location PR0521141 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> ` 0 M HW GEN<5 TONSNR PR0518064 EE0002646-THUY TRAN -*eb s Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOtPRO518065 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0518066 EE0000000-HAZ MAT SJC CES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPRO531388 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project specific,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 andror 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 I / <br /> Payment Type Check Number 'n Racal �1 <br /> RENS: Date �—7 , Account out: Date �\ <br /> COMMENTS: <br /> �o <br /> 22.21 �(l <br />