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Date mn 3/19/2015 2:57:29PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Reporta50zl <br /> Run by Pagel <br /> _ Facility Information as of 3/19/2015 <br /> Record Selection Criteria: Facility ID FA0021244 <br /> Make changesi corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0017513 New Owner ID <br /> Owner Name J & R ENVIRONMENTAL <br /> Owner DBA <br /> Owner Address 27226 VIA INDUSTRIA <br /> TEMECULA, CA 95290-3751 <br /> Home Phone 951-567-3805 <br /> Work/Business Phone 951-567-3805 <br /> Mailing Address 43422 Calle De Velardo <br /> TEMECULA, CA 92592 <br /> Care of MILES, ADAM H <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FAD021244 10187789 <br /> Facility Name J & R ENVIRONMENTAL <br /> Location 7557 W CARMELO AVE <br /> Tracy, CA 95304 <br /> Phone 951-567-3805 X <br /> Mailing Address 43422 Calle De Velardo <br /> TEMECULA, CA 92592 <br /> Care of MILES, ADAM H <br /> Location Code Alt Phone <br /> BOIS District 005- ELLIOTT, BOB Fax <br /> APN 25014014 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 AR0038395 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name J & R NTAL r (Circle one) <br /> Account Balance as of 3/19/201k_!7 58.00 <br /> Q/ (Circle One) <br /> TransferActive <br /> Pmgmrn ElemenNew OvmeR <br /> t and Description Record ID Employee ID and Name Status e Delete e <br /> 1921 -HMBP-Regular-Primary Location PRO537276 EE0002474-MICHAEL PARISSI Active Y N A? D <br /> 2220-SM HW GEN<5 TONSNR PRO536999 EE0002646-THUY TRAN Active Y N A D <br /> 2239-REMOTE WASTE CONSOLIDATION SITE PR0538412 EE0002646-THUY TRAN Active,l Y N A D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO538133 EE0002620-ALFONSO ARAMBULA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0537000 EE0002646-THUY TRAN Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS1EHD 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 pamormed in accordance with all applicable Ordinance Codes ardor Stancieds and State andor <br /> Federal Laws. / .�o <br /> APPLICANT'S SIGNATURE: �Ie.� - �Q.V bac - 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 Received y <br /> RENS: Date Account out: _ Date -3 <br /> COMMENTS: <br /> Set-.r/orc� <br />