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Dateb�_ -2/1012010 9:57:40A11r <br /> SAN J(--`� JIN COUNTY ENVIRONMENTAL HEA' I DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 211012 Pagel <br /> [Record selection Criteria: Facility ID FA0005302 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN I Fed Tax ID <br /> Owner ID OW0003473 New Owner ID <br /> Owner Name SPRECKELS SUGAR CO <br /> Owner DBA SPRECKELS SUGAR COMPANY <br /> Owner Address 20500 HOLLY DR <br /> TRACY, CA 953041649 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-835-3210 -` <br /> Mailing Address P}x.60 <br /> Care of <br /> T C� 3 b <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0005302 <br /> Facility Name SPRECKELS SUGAR COMPANY <br /> Location 20500 HOLLY DR <br /> TRACY, CA 95304 <br /> Phone 209-835-3210 <br /> Mailing Address PDJ30X-B0• <br /> T 8 <br /> Care of <br /> Location Code 03 -TRACY Alt Phone <br /> BOS District 005- ORNELLAS, LEROY 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 AR0005764 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name SPRECKELS SUGAR COMPANY (Circle One) <br /> Account Balance as of 2/10/2010: $592.00 <br /> (Circle One) <br /> Transfer to ActiveflnacNe <br /> ProgramlElement and Description Record ID Employee fD and[Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONSNR PRO513793 EE0005642-MICHELLE HENRY Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO511655 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PRO519583 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1184)-obsolete PRO502021 EE0005642-MICHELLE HENRY Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARiPR0507590 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PR0515794 EE0005642-MICHELLE HENRY Active,Exempt Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PRO531511 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project spec,PHSIEHD hourly charges associated with this <br /> facility 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I 1 <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date I I <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date I 1 <br /> Payment Type Check Number Received by <br /> RENS: Date I 1 Account out: �� Date :2 __I 10 <br /> COMMENTS: <br /> lleh-envlenvisionlreports15021.rpt <br />