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8/2007 4:43:36P SAN JOA COUNTY ENVIRONMENTAL HEAL PARTMENT Report#5021 <br /> Ru, Pagel <br /> Facility Information as of 10/18/200 <br /> )W <br /> Record iiteria: Facility ID FA0004478 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNErFILE INFORMATION <br /> Owner ID OW0003393 New Owner ID <br /> Owner Name PIONEER AMERICAS LLC 0 L't 'J <br /> Owner DBA PIONEER AMERICAS LLC <br /> Owner Address 700 LOUISIANA ST STE 4300 <br /> HOUSTON, TX 77002 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 700 LOUISIANA ST STE 4300 <br /> HOUSTON, TX 77002 <br /> Care o <br /> FACILITY FILE INF MATION <br /> acility ID FA0004478 O LI Lp2 L L( P pLL <br /> Fact ity Name <br /> ocation 26700 S BANTA RD Roti/: -Ttf f —IvKES <br /> TRACY, CA 95376 <br /> P e 209-835-5424 X D 2,(f <br /> Mailing Address 7 'S KC X45 S <br /> Care of t IS;4 AY—T44GK <br /> Location Code 99- UNINCORPORATED AREA APN:25215008 <br /> BOS District 005-ORNELLAS, LEROY SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR000004160 New Account ID: <br /> Mail Invoices to: Owner / Facility / Account <br /> Mail Invoices to Facility <br /> (Circle One) <br /> Account Name PIONEER AMERICAS LLC <br /> Account Balance as of 10/18/2007: $49.00 y/� !Q'"� / /// (Circle One) <br /> // !v ! / ' / Transfer r Activelete ve <br /> ( / New Owner? Delete <br /> Program/Element and DescriptionwwW Record ID Employe ID and I� Status <br /> 2960-RWQCB SITE PRO506297 EE0000997-HARLIN KNOLL Active Y N A I D <br /> 4633-TNC WATER SYSTEM WA0461320 EE0005838-ADRIENNE ELLSAESSEActive 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 /> Slate 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 Receive ! la <br /> REHS: Date Account out: Date�/02 / <br /> COMMENTS: <br /> \\phs-ehsq I-nt\apps\envisions\reports\5021.rpt <br />