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owe run 6/5/2014 4:48:45PM SAN JOA IN COUNTY ENVIRONMENTAL HEALDEPARTMENT <br /> un by <br /> Report 13021 <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) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : <br /> Owner ID OW0013289 New Owner ID <br /> Owner Name Millard Refrigerated Services <br /> Owner DBA MILLARD REFRIGERATED SERVICES <br /> Owner Address 730 SPRECKELS ROAD <br /> MANTECA, CA 95336 V <br /> Home Phone Not Specified <br /> Work/Business Phone 402-896-6600 <br /> Mailing Address 13030 PIERCE ST. 6A V <br /> Omaha, NE 68144 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0016416 10185169 <br /> Facility Name MILLARD REFRIGERATED SERVICES <br /> Location <br /> MANTECA, CA 95336 <br /> Phone 209-239-2888 x <br /> Mailing Address 730 SPRECKELS ROAD <br /> MANTECA, CA 95336 <br /> Care of Millard Refrigerated Services <br /> Location Code 04-MANTECA Alt 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 AR���0_0�28877 n NewAccount ID: <br /> Mail Invoices to qwy r t/,4 )A,1 �0 & A Mail Invoices to: Owner / Facility / Account <br /> Account Name Millard Refrigerated Ser ices"'�Lx��+ (Circle One) <br /> Account Balance as of 6/5/2014: $0.00 <br /> (Circle One) <br /> Transfer <br /> Program/Demenl and Description Record ID Employee ID and Name Stalus <br /> Newwto Active <br /> Omer? Delete <br /> 1921 -HMBP-Reqular-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-CalARP FAC STATE SURCHARGE FEE PRO524843 EEOOO0000-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 undersignetl owner,operator or agent of same,acknowledge that all site,andor project specific,PHSrEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this forth. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <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 T h ck Number Receit a <br /> REHS: �o ✓�ti� Date / Account out: Date <br /> COMMENTS: <br />