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Date run 7/27/2004 11:24:37AI SAN J UIN COUNTY ENVIRONMENTAL HEA 4 DEPARTMENT <br /> Report#5021 <br /> Run by Paget <br /> Facility Information as of 7/27/2UU4 <br /> Record Selection Criteria: Facility ID FA0011223 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0009223 Case Number: H09489 New Owner ID <br /> Owner Name TEICHERT AGGREGATES <br /> Owner DBA TEICHERT AGGREGATES (BIRD) <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 916-484-3011 <br /> Mailing Address PO BOX 15002 <br /> SACRAMENTO, CA 95851 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0011223 <br /> Facility Name TEICHERT AGGREGATES <br /> Location 36314 S BIRD RD <br /> TRACY, CA 95304 <br /> Phone 209-839-2666 <br /> Mailing Address PO BOX 15002 <br /> SACRAMENTO, CA 95851 <br /> Care of <br /> Location Code 99 - UNINCORPORATED AREA APN:26508013 <br /> BOS District 005- ORNELLAS, LEROY SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0018223 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name TEICHERT AGGREGATES (Circle One) <br /> Account Balance as of 7/27/2004: $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 /> 2220-SM HW GEN<5 TONS/YR PRO517543 EE0007380-STEVEN SHIH Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0513511 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0520759 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0511223 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: '$155.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\Phs-eh sq I-n t\apps\E n visions\Re ports\5021.rpt <br />