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Date run 10/25/2012 3:51:46P SAN JOIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT <br /> Report#5021 <br /> Run by <br /> Facility Information as of 10/25/2012 Pagel <br /> Record Selection Criteria: E,-:!Ny ID FA0010987 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) b 2 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008987 Case Number: H09106 New Owner ID <br /> Owner Name PACIFIC COAST SUPPLY LLC <br /> Owner DBA PACIFIC COAST SUPPLY LLC <br /> Owner Address 4290 ROSEVILLE RD <br /> NORTH HIGHLANDS, CA 95660 <br /> Home Phone Not Specified <br /> Work/Business Phone 916-444-9304 <br /> Mailing Address 4290 ROSEVILLE RD <br /> NORTH HIGHLANDS, CA 95660 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010987 <br /> Facility Name ANDERSON TRUSS <br /> Location 2050 E LOUISE AVE <br /> LATHROP, CA 95330 <br /> Phone 209-858-5584 <br /> Mailing Address 4290 ROSEVILLE RD <br /> NORTH HIGHLANDS, CA 95660 <br /> Care of PACIFIC COAST SUPPLY LLC <br /> Location Code Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 19816002 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 AR0017987 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name ANDERSON TRUSS (Circle One) <br /> Account Balance as of 10/25/2012: $0.00 <br /> (Circle One) <br /> Transfer to Aclive/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> -192�1 -HMBP-Regular-Primary Location PR0520589 EE0002474-MICHAEL PARISSI Inactive Y N A I D <br /> HW GEN<5 TONS/YR PR0514483 EE0002646-THUY TRAN --AQ W0— Y N A D <br /> HAZ MAT BUSINESS PLAN AUTHORIZATIOPPR0513275 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> UNIFIED PROGRAM FAC STATE SURCHAR(PR0510987 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ST FAC 10 K-</=100 K GAL CUMULATIVEPRO516363 EE0002646-THUY TRAN Y N A G D <br /> ASTE TIRE SITE-EXEMPT PR0524248 EE0007379-AMANDA BOERTIEN Inactive Y N A I D <br /> ERSC- LECTRONIC REPORTING STATE SURCH,PR0534450 Active Y N A (�D D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD 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 ancvor Standards and Stale and/or <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 Re`ce.vv by <br /> REHS: T&i I I Jli Date�(�/� / 17 Account out: Date <br /> COMMENT,5: <br /> S <br /> 24� vel t9IZ,6f(1— <br />