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Date run 9/13/2012 9:05:38AN SAN" IN COUNTY ENVIRONMENTAL HEAV DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/13/2012 <br /> Record Selection Criteria: Facility ID FA0007648 <br /> 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 OW0002996 New Owner ID <br /> Owner Name DDRW(SHARPE) <br /> Owner DBA <br /> Owner Address 850 ROTH RD <br /> LATHROP, CA 95330 <br /> Home Phone 209-982-2098 <br /> Work/Business Phone 904-332-3318 <br /> Mailing Address 2870 GATEWAY OAKS DR STE 300 <br /> SACRAMENTO, CA 958334324 <br /> Care of URS CORP ATTN RICHARD VAN DYKE <br /> FACILITY FILE INFORMATION <br /> Facility ID FAD007648 <br /> Facility Name DDRW-SHARPIES <br /> Location 850 E ROTH RD BLDG S-108 <br /> LATHROP, CA 95330 <br /> Phone <br /> Mailing Address 850 ROTH RD <br /> LATHROP, CA 95330 <br /> Care of PETER KALLISH (ASCW-BE) <br /> Location Code 07- LATHROP Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 19802001 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name KALZTSFfPE-TER <br /> Title <br /> Day Phone 20 - - 088 �- <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0012869 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / FacilityAccount <br /> Account Name URS (Circle One) <br /> Account Balance as of 9/13/2012: $0.00 <br /> 1 J�'A (Circle One) <br /> Progran✓Element and Description Recortl ID Em to ee ID antl Nama c��' )f Transfer to Activerinaetve <br /> Employee `{OY/ILJ W^ Status New Owner? Delete <br /> 2960-RWQCB SITE PR0506824 EE00g9999--.kARHhY1fNOLrI Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHS/EHD hourly chargee 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 andior Standards and State now <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 Check Number R ce' ed by <br /> REHS: Date_/_/_ Account out: ._ Date <br /> COMMENTS: <br /> V? fie, Aa. - <br />