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Date run 4/5/2012 10:31:57AM SAN 7UIN COUNTY ENVIRONMENTAL HE H DEPARTMENT <br /> Report#5021 <br /> Run by Pagel <br /> Facility Information as of 4/5/20.12 <br /> Record Selection Criteria: Facility ID FA0005674 <br /> Make changes/corrections in RED ink. i <br /> INFORMATION CHANGE(date) 24�� <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0004496 New Owner ID <br /> Owner Name OM SCOTT& SONS <br /> Owner DBA OM SCOTT& SONS/HYPONEX CORP <br /> Owner Address 23390 E FLOOD RD <br /> LINDEN, CA 95236 <br /> Home Phone Not Specified <br /> Work/Business Phone 937-644-0011 <br /> Mailing Address PO BOX 479 <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0005674 <br /> Facility Name OM SCOTT& SONS/HYPONEX CORP <br /> Location 23390 E FLOOD RD <br /> LINDEN, CA 95236 <br /> Phone 209-887-3845 <br /> Mailing Address PO BOX 479 <br /> LINDEN, CA 95236 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 09310017/1003 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name JERRY WOOLSEY <br /> Title <br /> Day Phone 209-887-3845 <br /> Night Phone 209-887-3845 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0006336 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name OM SCOTT& SONS/HYPONEX CORP (Circle One) <br /> Account Balance as of 4/5/2012: $0.00 ` / _ <br /> 7 I Z r� j l /L) K '_ I✓�f �7Arcl One) <br /> l__ � (. C /�r Transfer to Aclive/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0519995 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0517888 EE0009488-JEFFREY WONG Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOPPR0512258 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0503070 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0509970 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 4443-SW COMPOST SITE PR0505566 EE5555555-Garrett Alias-Backus Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH4PR0531915 Active Y N A I D <br /> 4630-NTNC WATER SYSTEM WA0505054 EE0005838-ADRIENNE ELLSAESSEActive Y N <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 andror Standards and State 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 I / <br /> Payment Type Check Number Recei <br /> REHS: Il 1� Date _/�_/� Account out: Date / 1�, <br /> COMMENTS: <br />