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Date ran 2/20/2014 12,46:57PI SAN JC, UIN COUNTY ENVIRONMENTAL HEA, ( DEPARTMENT Repo"#5021 <br /> Run by >•/ ` W Pagel <br /> Facility Information as of 2/20/2014 <br /> Record Selection Criteria: Facility ID FA0015002 <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 OW0011999 New Owner ID <br /> Owner Name LARRY DYCK <br /> Owner DBA MASCO SWEEPERS <br /> Owner Address 901 E LODI AVE <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work(Business Phone 800-345-1246 <br /> Mailing Address PO BOX 6312 <br /> SAN JOSE, CA 95150 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0015002 10,184,847 <br /> Facility Name MASCO SWEEPERS <br /> Location 901 E LODI AVE <br /> LODI, CA 95240 <br /> Phone 800-345-1246 x0 <br /> Mailing Address PO BOX 6312 <br /> SAN JOSE, CA 95150 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 04906027 lc <br /> �E/M�ail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone A <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0025638 oY �� New Account to: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name MASCO SWEEPERS (circle One) <br /> Account Balance as of 2/20/2014:4593-617-' <br /> (Circle One) <br /> Transfer to Aclive/Insdve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 1921 -HMBP-Regular-Primary Location PR0522030 EE0008709-JAMIE DE LA ROSA Active Y N A 8 D <br /> 2220-SM HW GEN<5 TONS/YR PR0523513 EE0001422-ARIS CACAPIT Active Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532960 Inactivit Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specHic,PHSIEHD 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 and State ander <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment TyplCheck Number Recei y <br /> RENS: Xzul - Date / / ILI Account out: Date_/ l <br /> COMMENTS: <br /> 2�ul�i K i S no Laaay- - ;n ode,a,h Cn a+ +his 00,:3 re <br />