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Report#5021 <br /> DatenAW-4m 211112014 11:35:22A[ SAN JC TIN COUNTY ENVIRONMENTAL HEA 4 DEPARTMENT <br /> Run by Pagel <br /> Facility Information as of 2/1312014 <br /> Record Selection Criteria: Facility ID FA0009929 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0007929 Case Number: H05859 New Owner ID <br /> Owner Name RAUSSER BROS TRUCKING INC <br /> Owner DBA RAUSSER BROS TRUCKING INC <br /> OwnerAddress 12000 E LIBERTY RD <br /> GALT, CA 95632 <br /> Home Phone Not Specified <br /> WorkJBusiness Phone 209-368-0654 <br /> Mailing Address +20ee-E--±ff3Efff"D <br /> GALT, CA 95632 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0009929 10,183,039 <br /> Facility Name RAUSSER BROS TRUCKING INC <br /> Location 12000 E LIBERTY RD <br /> GALT, CA 95632 <br /> Phone 209-368-0654 <br /> Mailing Address 1-2e00-E_L4BERT_y_4Rq Y, <br /> GALT, CA 95632 <br /> Care of GREG J RAUSSER <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> SOS District 004-VOGEL, KEN Fax <br /> APN 00722014 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 AR0016929 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility 1 Account <br /> Account Name RAUSSER BROS TRUCKING INC (Circle One) <br /> Account Balance as of 2/1312014: $1,898.00 <br /> (Circle One) <br /> Transfer to AcAive/Inactve <br /> Program/Element and Description Record 10 Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO519967 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0514098 EE0001 422-ARIS CACAPIT Active Y IN A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHOR17-ATION PRO512217 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO509929 EEOOOOOOO-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0515760 EE0001422-ARIS CACAPIT Active,/ Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0526316 EE0002622-BENJAMIN ESCOTTO Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO533463 Inactive Y N A 1 1) <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,and/or 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 ancyor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I <br /> Program Records to be TRANSFERED: $25.00= Amount Paid Date I <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Receivp Py? <br /> REHS: Date Account out: Date r 1 07 y <br /> COMMENTS: <br />