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•'"emn 215/2011 11:04:18AI SAN JO? TIN COUNTY ENVIRONMENTAL HEAL' DEPARTMENT Report 05021 <br /> Run oy Pagel <br /> Facility Information as of 2I15/201� <br /> Record Selection Criteria: Facility ID FA0009443 <br /> F �1. Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION -- SSNIFed Tax ID : <br /> Owner ID OW0007443 Case Number: H04023 New Owner ID <br /> Owner Name LEAR/HAYASHI TELEMPU <br /> Owner DBA AMTEX INC <br /> Owner Address 550 CARNEGIE ST <br /> MANTECA, CA 95337 <br /> Home Phone Not Specified <br /> Work/Business Phone 248-447-1500 �L <br /> Mailing Address -66&iCART 5 00 S V�+ "(- <br /> Vr_.�aCil VIAP N na L\ SO 3 b <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009443 <br /> Facility Name AMTEX INC <br /> Location 550 CARNEGIE ST <br /> MANTECA, CA 95337 <br /> Phone 209-239-9095 <br /> Mailing Address g§g_C,ARREGM c� n.� <br /> MA4TEeA-,e*-95S7 <br /> Care of <br /> Location Code 04-MANTECA Alt Phone <br /> BOS District 005- ORNELLAS, LEROY Fax <br /> APN 22119052 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> AccountlD AR0016443 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name AMTEX INC (circle One) <br /> Account Balance as of 2/15/2011: $607.00 <br /> (Circle One) <br /> Transfer to Active/Inacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Omer? Delete <br /> 2220-SM HW GEN c5 TONS/YR PR0513839 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO511731 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2226-CaIARP PROGRAM PRO514590 EEOOOOOOO-HAZ MAT SJC DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PRO519564 EEOOOOOOO-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0509443 EEOOOOOOO-HAZ MAT SJC IDES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0534087 Active 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 specific,PHS/EHD hourly charges associated with this <br /> facility 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 Ordinace Codes andfor standards and <br /> state and/or Federal Laws. ��cV�� ,r o ,,1p�, <br /> APPLICANT'S SIGNATURE: t'_ 'L \Mj Xxt�u�..r� "-a Lu ""'"'� Date 2 I 0A <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / I <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Receiverd�rbc, <br /> REHS: Date / / Account out: I V 'r Date -2—/ \-S / Ilk <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />