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Date run 1/2 F14 10:52:20AI SAN JOWIN COUNTY ENVIRONMENTAL HEAL Report#5027 <br /> DEPARTMENT Pagel <br /> Run by. • Facility Information as of 1/29/2014 <br /> Record Selection Catena: Facility ID FA0019471 <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 OW0015959 New Owner ID <br /> Owner Name SHIMMICK CONSTRUCTION CO INC <br /> Owner DBA SHIMMICK CONSTRUCTION CO INC <br /> Owner Address 23623 S BIRD RD <br /> TRACY, CA 95304 <br /> Home Phone Not Specified <br /> Work/Business Phone 510-777-5000 <br /> Mailing Address 23623 S BIRD RD <br /> TRACY, CA 95304 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0019471 10187255 <br /> Facility Name SHIMMICK CONSTRUCTION CO INC <br /> Location 23623 S BIRD RD <br /> TRACY, CA 95304 <br /> Phone 209-830-6500 x0 <br /> Mailing Address 23623 S BIRD RD <br /> TRACY, CA 95304 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN 25010003 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION New Account ID: <br /> Account ID AR0034621 <br /> Mail Invoices to: Owner I Facility / Account <br /> Mail Invoices to Owner (Circle One) <br /> Account Name SHIMMICK CONSTRUCTION CO INC <br /> Account Balance as of 1/29/2014: $0.00 (Circle One) <br /> Transfer to Active/Inadve <br /> Program/Element end Description Record ID Employee ID and Name tu <br /> Stas New Owneo Delete <br /> PR0529204 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532820 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andbr project specific,PHS/EHD hourly charges associatetl with this facility <br /> ER on this form. I also certify that all operations will be performed in accordance with all applicable ordinance Codes and'or Standards and state anovar <br /> or activity will be billed to the party identifiedED as the OWN <br /> Federal Laws. <br /> Date <br /> APPLICANT'S SIGNATURE: <br /> Amount Paid Date <br /> Program Records to be TRANSFERED: "$25.00= ate <br /> Water System to be TRANSFERED: Amount Paid Received Date <br /> Payment Type Check Number ,. <br /> by <br /> REHS: �nl A1C– <br /> Date�_/sem/�— Account out: Date <br /> COMMENTS: <br /> �1� 2ti2o P <br /> Tk.o5� g6� I <br />