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Date run 11/6/2013 3:45:07PR SAN JC JIN COUNTY ENVIRONMENTAL HEA! DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 11/6/2013 <br />Record Selection Criteria: Facility ID FA0013634 <br />Make changes/corrections in RED ink. <br />l <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION SSN / Fed Tax ID <br />Owner ID OW0010747 New Owner ID <br />Owner Name VACCEREZZA, DAVID M <br />Owner DBA CALIFORNIA WASTE RECOVERY SYST <br />Owner Address 980 E AUGUSTA ST <br />WOODBRIDGE, CA 95258 <br />Home Phone Not Specified <br />Work/Business Phone Not Specified <br />Mailing Address PO BOX 670 <br />WOODBRIDGE, CA 952580670 <br />Care of DAVID M VACCEREZZA <br />FACILITY FILE INFORMATION <br />Facility ID/CERS ID FA0013634 10,184,471 <br />Facility Name CALIFORNIA WASTE RECOVERY SYSTEM; <br />Location 1065 E TURNER RD <br />LODI, CA 95240 <br />Phone 209-369-6887 <br />Mailing Address PO BOX 670 <br />WOODBRIDGE, CA 952580670 <br />Care of DAVID M VACCEREZZA <br />Location Code 02 - LODI Alt Phone <br />BOS District 004 - VOGEL, KEN Fax <br />APN 04902038 Entail: <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0022789 New Account ID: <br />Mail Invoices to Facility Mail Invoices to: Owner / Facility / <br />Account <br />Account Name CALIFORNIA WASTE RECOVERY SYSTEMS (Circle One) <br />Account Balance as of 11/6/2013: $0.00 <br />(Circle One) <br />Transfer to <br />Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? <br />Delete <br />1920 - HMBP-Common Materials PR0527690 EE0008709 - JAMIE DE LA ROSA Active Y N <br />A D <br />GEN 5<25 TONS PERMIT PR0528796 EE0001422 - ARIS CACAPIT Active Y N <br />A T' D <br />3 AST FAC >/= 1,320 - <10 K GAL CUMULATIVE PRO534844 EE0001422 -ARIS CACAPIT Active,l Y N <br />A D <br />23 - REFUSE VEHICLES PR0517968 EE0002620 - ALFONSO ARAMBULA Inactive Y N <br />A I D <br />4740 - WASTE TIRE SITE - EXEMPT PR0534997 EE0002620 - ALFONSO ARAMBULA Inactive Y N <br />A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0532038 Inactive 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 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 and/or Standards <br />and Stale andlor <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 Receive / 7 / <br />REHS: �i� Date / t> / Account out: �/1 Date �/-/_3 <br />COMMENTS: � � /� <br />2LI( q( gll� /�� / <br />