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Date run 6/5/2014 4:44:53PM <br /> Run by SAN JOA.;IN COUNTY ENVIRONMENTAL HEAI�DEPARTMENT <br /> ' Report#5027 <br /> 11 <br /> Facility Information as of 6/5/2014 Pagel <br /> Record Selection Criteria: Facility ID FA0016416 <br /> Make changes/corrections in RED Ink. <br /> INFORMATION CHANGE(date) (/)UNCI <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 <br /> SSN/Fed Tax ID <br /> Owner ID OW0013289 New Owner ID <br /> Owner Name LARSEN, LARRY <br /> Owner DBA MILLARD REFRIGERATED SERVICES <br /> Owner Address 730 SPRECKELS ROAD <br /> MANTECA, CA 95336 <br /> Home Phone Not Specified <br /> Work/Business Phone 402-896-6600 <br /> Mailing Address 730 SPRECKELS ROAD <br /> MANTECA, CA 95336 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0016416 10185169 <br /> Facility Name MILLARD REFRIGERATED SERVICES <br /> Location 730 SPRECKELS ROAD <br /> MANTECA, CA 95336 <br /> Phone 402-896-6600 x0 <br /> Mailing Address 730 SPRECKELS ROAD <br /> MANTECA, CA 95336 <br /> Care of <br /> Location Code 04 - MANTECA Ah Phone <br /> Bos District 005- ELLIOTT, BOB Fax <br /> APN 22121017 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 AR0028877 New Account to: <br /> Mail Invoices to r' P'f}t4/0'T" I"'Phi&6"k5 Mail invoices to: Owner / Facility / Account <br /> Account Name LARSEN, LARRY Y 1 (Circle One) <br /> Account Balance as of 6/5/2014: $0.00 <br /> (Circle ore) <br /> Transfer to ActivelmicNe <br /> Progra rvElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO524473 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 1963-CaIARP PROGRAM 3 FACILITY PRO535585 EE0008317-RAYMOND VON FLUE Active Y N A I D <br /> 1995-CaIARP FAC STATE SURCHARGE FEE PRO524843 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO538502 EE0009001 -ELENA MANZO Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0524566 EE0004045-TED TASIOPOULOS Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531966 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 specific,PHSIEHD hourly charges associated with this really <br /> or activity will be billed to the party identnied as the OWNER on this forth I also certify that all operations will be performed in accordance with all applicable Ordinance Codes ardor standards and State ands <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 y��9/p a Check Number Rem! <br /> COMMSS r.. V U� Date / r�� Account out: Date <br /> COMMENT I <br />