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oat. run 9/13/2011 2:55:32PR SAN 3p�IN COUNTY ENVIRONMENTAL HEAI DEPARTMENT I' <br />Run by `_ <br />Report 05021 <br />Facility Information as of 9/13/2Q11 Page' <br />Record Selection Criteria: <br />OWNER FILE INFORMATION <br />Owner ID OW0007917 Case Number: H05810 <br />Owner Name <br />PAT MITCHELL <br />Owner DBA <br />CALIFORNIA NATURAL PRODUCTS <br />Owner Address <br />1250 E LATHROP RD <br />I D <br />LATHROP, CA 95330 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-931-9502 <br />Mailing Address PO BOX 1219 <br />LATHROP, CA 95330 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID FA0009917 <br />Facility Name CALIFORNIA NATURAL PRODUCTS <br />Location 1250 E LATHROP RD <br />LATHROP, CA 95330 <br />Phone 209-858-2525 <br />Mailing Address PO BOX 1219 <br />LATHROP, CA 95330 <br />Careof PATMITCHELL <br />Location Code <br />BOIS District 003 - BESTOLARIDES <br />APN 198-040-01-0 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0016917 <br />Mail lnvoicesto Facility <br />Account Name CALIFORNIA NATURAL PRODUCTS <br />Account Balance as of 9/13/2011: $0.00 <br />PrograrvElement and Description <br />Record ID Employee ID and Name <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) A <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID <br />Site Mitigation Facility <br />Ah Phone <br />Fax <br />EMail : <br />1A. /MMU <br />New Account ID: <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to ActivednacNe <br />Status New Owner? Delete <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0512205 <br />EE0000000 - HAZ MAT SJC DES <br />Inactive <br />Y <br />N <br />A <br />I D <br />122f- GEN 5<25 TONS PERMIT PRO517883 <br />EE0002646 - THUY TRAN <br />Active <br />Y <br />N <br />A <br />I D <br />22V -#RT TRANSFER RECORD - DES PRO519959 <br />EE0000000 - HAZ MAT SJC DES <br />Active <br />Y <br />N <br />A <br />I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHAR(PR0509917 <br />EE0000000 - HAZ MAT SJC DES <br />Inactive <br />Y <br />N <br />A <br />I D <br />2831 - AST FAC >/= 1,320 - <10 K GAL CUMULATNPR0535574 <br />EE0002646 - THUY TRAN <br />Active,Exempt <br />Y <br />N <br />A I <br />D <br />ERSC - ELECTRONIC REPORTING STATE SURCH,PR0534671 <br />Active <br />Y <br />N <br />A I <br />D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned! owner, operator or agent of same, acknowledge that all site, and/or <br />project specific, PHSEHD <br />hourly charges associated <br />with this <br />facility or activity will be billed to the party identified as the OWNER on this form. I also <br />certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards <br />and <br />State and/., Federal Laws. <br />APPLICANTS SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: • $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date / / <br />Payment Type��,/ Check Number Recap y <br />REHS: C� �'k to Date l Account out: Date :ZL 111— <br />COMMENTS: <br />TqEmx Gee t CO& aa-aq -5� a;gao - -1�4-1 2vio Lfr- 6e4'A$a d.v&r <br />C:\DOCUME-1 \tttran\LOCALS-1 \�\a021 2 0 3338C0 -4C59 -92C <br />