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Date run 12/19/2017 8:50:36A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/19/2017 <br /> Record Selection Criteria: Facility ID FA0015161 <br /> Make changesicorrections 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 OW0012141 New Owner ID <br /> Owner Name Basalite Concrete Products LLC <br /> Owner DBA EPIC PLASTICS INC <br /> OwnerAddress 605 INDUSTRIAL WAY <br /> DIXON, CA 95620 <br /> Home Phone Not Specified <br /> Work/Business Phone 707-678-1901 <br /> Mailing Address 605 Industrial Way <br /> Dixon, CA 95620 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0015161 10119757 <br /> Facility Name EPIC PLASTICS, INC. <br /> Location 104 E Turner Rd <br /> Lodi, CA 95240 <br /> Phone 209-333-6161 x <br /> Mailing Address 104 East Turner Road <br /> Lodi, CA 95240 <br /> Care of Epic Plastics <br /> Location Code 02- LODI Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 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 AR0026041 New Account ID: <br /> Maillnvoicesto Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Maureen Cleary (Circle one) <br /> Account Balance as of 12/19/2017: $0.00 <br /> (Circle One) <br /> Transferlo ActiveMacive <br /> ProgmmlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary-„ PRO 50 EE0008709-JAAaIE,LI <br /> 2221 -USED OIL ONLY-<5 TONS/ `-15R 7 EE9999998-ON����//AIve <br /> 4740-WASTE TIRE SITE-EXEMPT PRO526283 EE0007379-AMANDA BOERTIEN Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO532625 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 speck,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party idenCrfied as the OWNER on this form. 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 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: Invoice#: <br />