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Date run 12/1/2015 1:04:35PR SAN JO.`IIN COUNTY ENVIRONMENTAL HEAT- DEPARTMENT Report #5021 Run by J0* �C Pagel Facility Information as of 12/1/2015 Record Selection Criteria: ;tacility ID FA0013569 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0010689 Owner Name Thomas Asbury Owner DBA SUMMIT ROOFING SERVICES Owner Address 3131 BAY MEADOWS CT Phone LIVERMORE, CA 94550 Home Phone Not Specified WorkBusiness Phone 510-453-8468 Mailing Address 3131 Bay Meadows Ct Livermore, CA 94550 Care of FACILITY FILE INFORMATION Facility ID/CERS ID FA0013569 10184415 Facility Name SUMMIT ROOFING SERVICES Location 705 INDUSTRIAL PARK MANTECA, CA 95337-6115 Phone 209-825-3042 x Mailing Address 705 INDUSTRIAL PARK DR MANTECA, CA 95337-6115 Care of Summit Roofing Services Location Code 04 - MANTECA Bos District 005 - ELLIOTT. BOB APN 22119011 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0022678 Mail Invoices to Account Account Name SUMMIT ROOFING SERVICES Account Balance as of 12/1/2015: $0.00 Pmgram/Element and Description Record ID 1921 - HMBP-Regular-Primary Location PRO521088 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0517725 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0517726 ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0532087 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN/Fed Tax ID New Owner ID : 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 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. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: " $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date_// Payment Type Check Number Received by ! EHD Staff: moi_ /iiarl:J Date Account Account out: Date COMMENTS: — �� (e11.^, p— , r aa -W pP� j) ) ^ rngia-ccL` Invoice #: Alt Phone Fax EMail Mail Invoices to: Employee ID and Name EE0000010 - PETER LOMBARDI EE0000000 - HAZ MAT SJC DES EE0009903 - DOUG WILSON New Account ID: Owner / Status Active Inactive Inactive Inactive Facility / (Circle One) Transferto New Owner? Y N Y N Y N Y N Account (Circle One) Activefnaclve Delete A I D A 1 D A I D A I D 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 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. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: " $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date_// Payment Type Check Number Received by ! EHD Staff: moi_ /iiarl:J Date Account Account out: Date COMMENTS: — �� (e11.^, p— , r aa -W pP� j) ) ^ rngia-ccL` Invoice #: