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Date run, 4/22/2016 4:03:45PN SAN 3 IN COUNTY ENVIRONMENTAL HEA `DEPARTMENT Report#5021 <br /> Run by 0 Pagel <br /> Facility Information as of 4/22/2016 <br /> Record Selection Criteria: Facility ID FA0010222 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN I Fed Tax ID <br /> Owner 1D OW0008222 Case Number: H07375 New Owner ID <br /> Owner Name RICHARD JOAQUIN <br /> Owner DBA R&B PROTECTIVE COATINGS INC <br /> Owner Address 19968 E HWY 26 <br /> LINDEN, CA 95236 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-986-9891 <br /> Mailing Address PO BOX 652 <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0010222 10183337 <br /> Facility Name R&B PROTECTIVE COATINGS INC <br /> Location 19968 E HWY 26 <br /> LINDEN, CA 95236 <br /> Phone 209-887-2030 x <br /> Mailing Address PO BOX 652 <br /> LINDEN, CA 95236 <br /> Care of Shelley Joaquin <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 004 -WIN N, CHARLES Fax <br /> APN 10527004 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 AR0017222 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name R&B PROTECTIVE COATINGS INC (Circle One) <br /> Account Balance as of 412212016: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO620155 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONSIYR PRO527189 EE0000027-CINDY VO Active Y N A 1 0 <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512510 EEo000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2299-WASTE GENERATING RECYCLER PRO529416 EE0000027-CINDY VO Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE R PRO510222 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PR0529334 EE0009488-JEFFREY WONG Inactjve Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO532117 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,PHSIEHD 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 andfor Standards and State andror <br /> Federal Laws, <br /> APPLICANT'S SIGNATURE: Date I 1 <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date I 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date 1 1 Account out: Date 1 1 <br /> COMMENTS: <br /> Invoice#: <br />