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Date nm 1/21/2010 9:21:06AN SAN JO' -UIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021, <br /> Run by Pagel <br /> Facility Information as of 1/21/201u <br /> Record Selection Criteria: Facility ID FA0010966 <br /> e 1 Make changes/corrections in RED ink. <br /> / INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008965 New Owner ID <br /> Owner Name CONCRETE INC <br /> Owner DBA CONCRETE INC /— <br /> Owner Address PO BOX 66001 <br /> STOCKTON, CA 95206 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 66001 <br /> STOCKTON, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010966 <br /> Facility Name CONCRETE INC <br /> Location 851 E LODI AVE <br /> LODI, CA 95240 <br /> Phone 209-333-6380 <br /> Mailing Address PO BOX 66001 <br /> STOCKTON, CA 95206 <br /> Care of <br /> Location Code 02 -LODI Alt Phone <br /> BOS District 004-VOGEL, KEN Fax IC'4/ 'FS <br /> APN 04906012 EMail: ob L N l c r ✓c,r.K.cry <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION I <br /> Contact Nameoan Ld`�'C err <br /> Title BNC'rrY Ir/�+Nl}�)Yt—� <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID <br /> AR0017966 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name CONCRETE INC (Girds Ono <br /> Account Balance as of 1/21/2010: $0.00 <br /> (Circe One) <br /> Transfer to Achve/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO517959 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513254 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PRO520580 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0510966 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigns 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 o i form I also certify that all operations will be performed in accordance with all applicable Ordinate Codas and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRA FERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFtRED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Receivedlby f) <br /> REHS: '� r ! Date S /�/� ) Account out Date / <br /> COMMENTS: <br /> \\eh-env\envision Veports\5021.rpt <br />