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Date run t 1/15/2014 9:05:47AN SAN JOIN COUNTY ENVIRONMENTALHEAIWEPARTMENT Report#5021 <br /> Ryn by Pagel <br /> Facility Information as of 1/15/2014 <br /> Record Selection Criteria: Facility ID FA0005608 <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 OW0004433 New Owner ID <br /> Owner Name RO TILE INC <br /> Owner DBA RO TILE MANUFACTURING LLC <br /> Owner Address 1625 STOCKTON ST <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 909-357-8295 <br /> Mailing Address 1625 S STOCKTON ST <br /> LODI, CA 952406353 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0005608 <br /> Facility Name RO TILE INC <br /> Location 1625 STOCKTON ST <br /> LODI, CA 95240 <br /> Phone 209-334-1380 <br /> Mailing Address 1625 S STOCKTON ST <br /> LODI, CA 952406353 <br /> Care of <br /> Location Code 02-LODI Alt Phone <br /> BOB District 004-VOGEL, KEN Fax <br /> APN 05737034 nAr'L6L-t— 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 AR0006241 New Account ID: <br /> Mail Invoices tom Mail Invoices to: Owner / Facility / Account <br /> Account Name RO TILE INC (Circle One) <br /> Account Balance as of 1/15/2014: $0.00 <br /> (Circle One) <br /> Transfer to Activ.1ractve <br /> PrograndElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0520808 EE0000000-HAZ MAT SJC IDES Inactive Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0513684 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO511462 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PRO502895 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509174 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,ander project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER an this form I also certify That all operations will be Performed in accordance with all applicable Ordinance Codes and'or Standards and State ancvor <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 <br /> COMMENTS: �i <br />