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Date run 5/24/2010 12:46:39PI SAN JG' -NUIN COUNTY ENVIRONMENTAL HEA' '-d DEPARTMENT Report#W21 <br /> Run by <br /> !./ Facility Information as of 5/24/2001ill Paget <br /> Record Selection Criteria: Facility ID FA0009948 <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 OW0007948 Case Number: H05977 New Owner ID <br /> Owner Name A&A ROSSI HAY SERVICE <br /> Owner DBA <br /> Owner Address 511 N AIRPORT WAY <br /> MANTECA, CA 95336 <br /> Home Phone 209-609-6954 <br /> Work/Business Phone 209-823-3965 <br /> Mailing Address PO BOX 332 <br /> MANTECA, CA 95336 <br /> Care of A&A ROSSI HAY SERVICE <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009948 <br /> Facility Name A&A ROSSI HAY SERVICE <br /> Location 511 N AIRPORT WAY <br /> MANTECA, CA 95336 <br /> Phone 209-823-3965 <br /> Mailing Address PO BOX 332 <br /> MANTECA, CA 95336 <br /> Care of <br /> Location Code 04-MANTECA Alt Phone <br /> BOS District 003-BESTOLARIDES Fax <br /> APN 19528009 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name DENA ROSSI <br /> Title <br /> Day Phone 209-609-6954 Cell <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016948 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name A&A ROSSI HAY SERVICE (Circle One) <br /> Account Balance as of 5/24/2010: $1,769.80 <br /> (Circle One) <br /> Transfer to Aclive/Inacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Ovmer.? Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO514106 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512236 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0519980 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2,2 UNIFIED PROGRAM FAC STATE SURCHARPR0509948 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> AST FAC >/=1,320-<10 K GAL CUMULATI\PRO515679 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0531871 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,aclmowledge that all site,arW/or project specific,PHS/EHD hourly charges associated With this <br /> facility an activity will be billed to the party identified as the OWNER on this form. I also certify Mat all operations will be performed in accordance mth all applicable Ordinace Codes anWor Standards and <br /> State andlor Federal Laws, <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date I / <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Receivsy�b <br /> RENS: W1 ,p�M1�� Date-5-LA-5-6)—VAccount out: �T Date to O l D <br /> COMMENTS: <br /> � a <br /> \\eh-env\envision\reports\5021.rpt <br /> o3at� <br />