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Date run 3/13/2008 4:51:22PN SAN JUIN COUNTY ENVIRONMENTAL HEJOH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/13/2008 <br /> Record Selection Criteria: Facility ID FA0013552 <br /> Make changesicorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0010675 New Owner ID <br /> Owner Name CAILLIER, ANDRE P <br /> Owner DBA A&A CONCRETE SUPPLY INC-TRACY <br /> Owner Address 8272 BERRY AVE <br /> SACRAMENTO, CA 95828 <br /> Home Phone Not Specified <br /> Work/Business Phone 916-383-3756 <br /> Mailing Address 8272 BERRY AVE <br /> SACRAMENTO, CA 95828 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013552 <br /> Facility Name A&A CONCRETE SUPPLY <br /> Location 10250 W LINNE <br /> TRACY, CA 953779128 <br /> Phone 209-830-5070 <br /> Mailing Address 8272 BERRY AVE <br /> SACRAMENTO, CA 95828 <br /> Care of <br /> Location Code 99- UNINCORPORATED AREA APN:253-120-40 <br /> BOS District 005 - ORNELLAS, LEROY SIC Code:9600 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022661 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name CAILLIER, ANDRE P (Circle One) <br /> Account Balance as of 3/13/2008: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO517694 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PRO520951 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARtPR0517693 EE0000000-HAZ MAT SJC OES Inactive 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 and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: `$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Rece'v d y <br /> REHS: Date Account out: Date / <br /> COMMENTS: <br /> AJJ ;0'31-0 <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />