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Date run 12/1/2015 1:04:35PR SAN JO.`IIN COUNTY ENVIRONMENTAL HEAT- DEPARTMENT Report #5021 <br />Run by J0* <br />�C Pagel <br />Facility Information as of 12/1/2015 <br />Record Selection Criteria: ;tacility ID FA0013569 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0010689 <br />Owner Name <br />Thomas Asbury <br />Owner DBA <br />SUMMIT ROOFING SERVICES <br />Owner Address <br />3131 BAY MEADOWS CT <br />Phone <br />LIVERMORE, CA 94550 <br />Home Phone <br />Not Specified <br />WorkBusiness Phone <br />510-453-8468 <br />Mailing Address <br />3131 Bay Meadows Ct <br />Livermore, CA 94550 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID/CERS ID <br />FA0013569 10184415 <br />Facility Name <br />SUMMIT ROOFING SERVICES <br />Location <br />705 INDUSTRIAL PARK <br />MANTECA, CA 95337-6115 <br />Phone <br />209-825-3042 x <br />Mailing Address 705 INDUSTRIAL PARK DR <br />MANTECA, CA 95337-6115 <br />Care of Summit Roofing Services <br />Location Code 04 - MANTECA <br />Bos District 005 - ELLIOTT. BOB <br />APN 22119011 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0022678 <br />Mail Invoices to Account <br />Account Name SUMMIT ROOFING SERVICES <br />Account Balance as of 12/1/2015: $0.00 <br />Pmgram/Element and Description Record ID <br />1921 - HMBP-Regular-Primary Location PRO521088 <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0517725 <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0517726 <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0532087 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN/Fed Tax ID <br />New Owner ID : <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, antl or project specific, PHS�EHD hourly charges associated with this facility or <br />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 ander Standards and State and'or Federal Laws. <br />APPLICANT'S SIGNATURE: <br />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 by ! <br />EHD Staff: moi_ /iiarl:J Date Account Account out: Date <br />COMMENTS: — �� <br />(e11.^, p— , r aa -W pP� j) ) ^ rngia-ccL` Invoice #: <br />Alt Phone <br />Fax <br />EMail <br />Mail Invoices to: <br />Employee ID and Name <br />EE0000010 - PETER LOMBARDI <br />EE0000000 - HAZ MAT SJC DES <br />EE0009903 - DOUG WILSON <br />New Account ID: <br />Owner / <br />Status <br />Active <br />Inactive <br />Inactive <br />Inactive <br />Facility / <br />(Circle One) <br />Transferto <br />New Owner? <br />Y N <br />Y N <br />Y N <br />Y N <br />Account <br />(Circle One) <br />Activefnaclve <br />Delete <br />A I D <br />A 1 D <br />A I D <br />A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, antl or project specific, PHS�EHD hourly charges associated with this facility or <br />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 ander Standards and State and'or Federal Laws. <br />APPLICANT'S SIGNATURE: <br />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 by ! <br />EHD Staff: moi_ /iiarl:J Date Account Account out: Date <br />COMMENTS: — �� <br />(e11.^, p— , r aa -W pP� j) ) ^ rngia-ccL` Invoice #: <br />