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Dale run 3/2/2012 2:21:15PM SAN Jr f2UIN COUNTY ENVHtONMENTAL HE/ "H DEPARTMENT Report M21 <br /> Run by <br /> Facility Information as of 3/2/202 Pagel <br /> Record Selection Criteria: Facilrcy ID FA0010429 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008429 Case Number: H08084 New Owner ID <br /> Owner Name ANDREW SALMERON SR <br /> Owner DBA DOUBLE A TRUCK SVC <br /> Owner Address 1675 W CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Home Phone Not Specified <br /> Work/Business Phone 925-634-5020 <br /> Mailing Address FO BOX 1402 <br /> DISCOVERY BAY, CA 945057402 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010429 <br /> Facility Name DOUBLE A TRUCK SVC <br /> Location 1675 W CHARTER WAY D <br /> STOCKTON, CA 95206 <br /> Phone 209-467-0873 <br /> Mailing Address PO BOX 1402 <br /> DISCOVERY BAY, CA 945057402 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 16337010 Eli <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name ANDREW SALMERON SR <br /> Title OWNER <br /> Day Phone 209-467-0873 <br /> Night Phone 209-914-5653 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017429 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name DOUBLE A TRUCK SVC ccirde one) <br /> Account Balance as of 3/2/2012: J <br /> (Circle One) <br /> Transfer to Activenni lve <br /> PmgraMElemem and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0514324 EE0001421 -STACY RIVERA Active Y N A D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512717 EEOOOo000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PRO520314 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARFIR0510429 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPRO534770 Active Y N A 0 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 Ordinate Codes and/or Standards and <br /> State and/or 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 Type Check Number Receive y <br /> RENS: Date /� /�__Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />