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Date run 6/26/2017 9:00:45AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/26/2017 <br /> Record Selection Criteria: Facility ID FA0010987 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) G 'L -71ZJ17 <br /> OWNERSHIP CHANGE(date) 15 <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0008987 Case Number: H09106 Nq6owner ID- <br /> Owner Name R C e -et <br /> Owner DBA;_E,yCf.F) `r L <br /> OwnerAddress 42q JI- <br /> -NORTtt-F#1GtfLANDS;-GA,-956643' 2 <br /> Home Phone Not Specified <br /> Work/Business Phone <br /> Mailing Address :740 C tU,WL (A- <br /> NORTH 5660 1l <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0010987 10119784 <br /> Facility Name-AN-DEfZ501nzFR.kJ8S--- FI-2 a 1 <br /> Location 2050 E LOUISE AVE <br /> LATHROP, CA 95330 <br /> Phone 209--858-&58+ Q — <br /> Mailing Address 4 N A, <br /> N X66 <br /> Care of P- -`-LtC <br /> Location Code 07 - LATHROP Alt Phone <br /> BOS District 003 - BESTOLARIDES, STEVE Fax <br /> APN 19816002 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017987 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name ANDERSON TRUSS (Circle One) <br /> Account Balance as of 6/26/2017: $0.00 <br /> (Circle One) <br /> Transfer to Active/lnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0520589 EE0000009-NICHOLAS LOEHRER Inactive Y N I D <br /> 2220-SM HW GEN<5 TONS/YR PR0514483 EE9999997-TWO VACANT2 Inactive Y N I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513275 EE9999997-TWO VACANT2 Inactive Y N I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0510987 EE0000000-HAZ MAT SJC OES InactivE Y N A I D <br /> 2832-AST FAC 10 K-</=100 K GAL CUMULATIVE PR0516363 EE0002646-THUY TRAN InactivE Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0524248 EE0007379-AMANDA BOERTIEN Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0534450 InactivE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ancitor project specific,PHS/EHD hourly charges associated with this facility <br /> 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 Ordinance Codes ancl/or Standards and State anddor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: 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 b <br /> EHD Staff: 0 eA eV Date (v / 2.1/2 /7 Account out: Date /-2S J C7 <br /> COMMENTS: /-LL 1 VO_to /12-1 7 L1r ( )l m I L �� Invoice#: ( �'/� <br />