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Date run 5/13/2003 3:42:11Ph SAN JO, AN COUNTY ENVIRONMENTAL HEAL `DEPARTMENT Report#5021 <br />Run by 1*...,� ` Pagel <br />Facility Information as of 5/13/2003 <br />Record Selection Criteria: Facility ID FA0011051 <br />Make changes/corrections in RED i encil. <br />INFORMATION CHANGE <br />OWNERSHIP CHANGE (da e <br />OWNER FILE INFORMATION rus , <br />Owner ID OW0009051 Case Number: H09216 <br />Owner Name AMG RESOURCES PACIFIC CORP <br />Owner DBA AMG RESOURCES PACIFIC CORP <br />Owner Address <br />Home Phone Not Specified <br />Work/Business Phone 209-858-2458 <br />Mailing Address PO BOX 442 <br />LATHROP, CA 95330 <br />New Owner ID : <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID FA0011051 <br />Facility Name AMG RESOURCES PACIFIC CORP <br />Location 15332 S MCKINLEY AVE <br />LATHROP, CA 95330 <br />Phone 209-858-2458 <br />Mailing Address PO BOX 442 <br />LATHROP, CA 95330 <br />Care of DON NEW <br />Location Code <br />APN:198-040-07 <br />BOS District 003 - MOW, VICTOR <br />SIC Code:9900 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0018051 <br />New Account ID: <br />Mail Invoices to Facility <br />Mail Invoices to: Owner / <br />Facility / <br />Account <br />Account Name AMG RESOURCES PACIFIC CORP <br />(Circle One) <br />Account Balance as of 5/13/2003: $0.00 <br />(Circle One) <br />Transfer to <br />Active/Inactve <br />Program/Element and Description Record ID <br />Employee ID and Name Status <br />New Owner? <br />Del to <br />2217 - APPLIANCE RECYCLER PR0521574 <br />EE0008389 - DENNIS CATANYAG Active <br />Y N <br />A I D <br />2221 - USED OIL ONLY - <5 TONS/YR PR0514507 <br />EE0008317 - RAYMOND VON FLUE Active <br />Y N <br />A I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0513339 <br />EE0000000 - HAZ MAT SJC OES Active <br />Y N <br />A I D <br />2244 - PACT TRANSFER RECORD - OES PR0520635 <br />Active <br />Y N <br />A I D <br />2390 - ABOVEGROUND TANK (SPCC) PR0517371 <br />EE0007289 - ALISON YOUNGBLOODActive <br />Y N <br />A I D <br />2399 - UNIFIED PROGRAM FAC STATE SERVICE FPR0511051 <br />EE0000000 - HAZ MAT SJC OES Inactive <br />Y N <br />A I 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 <br />associated with this <br />facility or activity will be billed to the party identified as the OWNER on this form. I also <br />certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br />State and/or Federal taws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: * $20.00 = <br />Amount Paid Date <br />Water System to be TRANSFERED: * $155.00 = <br />Amount Paid Date <br />Payment Type Check Number <br />Received by <br />REHS: be-- Date / <br />/ Account out: --Date 03 <br />COMMENTS: <br />\\Phs-ehsql-nt\apps\Envisions\Reports\5021. rpt <br />