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Date run 7/26/2015 10:15:17AI SAN J IN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/28/2015 <br /> Record selection Criteria: Facility ID FA0022691 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0020379 New Owner ID <br /> Owner Name—NIPP©NSHE $ T AL <br /> Owner DBA L(Owner Address 500 E LOUISE AVE <br /> LATHROP, CA 95330 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 500 E LOUISE AVE <br /> LATHROP, CA 95330 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022691 <br /> Facility Name-p(bK}N6T-GN-NORTH AMERICA LATHROP- L bCc/� L-- <br /> Location 500 E LOUISE AVE <br /> LATHROP, CA 95330 <br /> Phone <br /> Mailing Address 1200 CONCORD AVE STE 200 <br /> CONCORD, CA 94520 <br /> Care of PARRY, DANA <br /> Location Code 07- LATHROP Alt Phone <br /> BOS District 003- BESTOLARIDES, STEVE Fax <br /> APN 19812008 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION 1 <br /> Contact Name P LK{N2rT6N-NORTH AMERICA C/ Q n��Gl' r Frown <br /> Title <br /> Day Phone 209-858-6292 <br /> Night Phone 209-858-6292 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0041555 NevvAccount ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name PILKINGTON NORTH AMERICA LATHROP (Circle One) <br /> Account Balance as of 7/28/2015: $0.00 <br /> (Circle One) <br /> Transfer to ActiveAnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PRO539645 EE0001699-JOHNNY YOAKUM Active Y N I D <br /> 2953-LCL HW CLEANUP SITE PRO640336 EE0001453-NUEL HENDERSON Active Y N AV I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project specific,PHSIEHD 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 andtor Standards and State anNar <br /> Federal Laws. <br /> APPLICANTS 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 Che kN,um"ber Receiv by <br /> EHD Staff: �i��^T'1.�7?? )=1'" Date_/ /_L.Zr_ Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />