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Date run 3/18/2016 3:33:03PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 3/18/2016 <br />Record Selection Criteria: Facility ID FA0010100 <br />Make changestcorrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION Number of facilities for this owner : 2 <br />Owner ID OW0008100 Case Number: H06547 <br />Owner Name <br />South Bay Foundry <br />Owner DBA <br />SOUTH BAY FOUNDRY <br />OwnerAddress <br />9444 ABRAHAM WAY <br />Status <br />SANTEE, CA 92029 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />619-596-3825 <br />Mailing Address <br />9444 Abraham Way <br />Care of <br />Santee, CA 92071-2853 <br />Care of <br />02 - LODI <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0010100 10183215 <br />Facility Name <br />SOUTH BAY FOUNDRY INC <br />Location <br />42 N CLUFF AVE <br />Status <br />LODI, CA 95240 <br />Phone <br />209-367-1940 x <br />Mailing Address <br />9444 Abraham Way <br />Active <br />Santee, CA 92071-2853 <br />Care of <br />South Bay Foundry <br />Location Code <br />02 - LODI <br />BOIS District <br />004 - WINN, CHARLES <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0017100 <br />Mail Invoices to Account <br />Account Name SOUTH BAY FOUNDRY INC <br />Account Balance as of 3/18/2016: $0.00 <br />Program/Element and Description <br />SSN / Fed Tax ID <br />New Owner ID : <br />Fax <br />EMail : <br />Record ID Employee ID and Name <br />1 /I P, - i <br />a // <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />1921 - HMBP-Reqular-Primary Location PR0512388 EE0008709 - JAMIE DE LA ROSA <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0510100 EE0000000 - HAZ MAT SJC GIES <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGI PR0532037 <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 facility or <br />be billed to the party identified as the OWNER on this form. I also cerWy that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State andror Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />PaymentTy Check Number Received b <br />EHD Staff: Date / / Account out: Date l�iLl <br />COMMENTS: <br />6u�i Invoice #: <br />CWO'lll, ULU as wn�Lw rW�abU "u <br />(Circle One) <br />Transfer to <br />Aclive/Inactve <br />Status <br />New Owner? <br />Delete <br />Active <br />Y N <br />A D <br />Inactive <br />Y N <br />A D <br />Inactive <br />Y N <br />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 facility or <br />be billed to the party identified as the OWNER on this form. I also cerWy that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State andror Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />PaymentTy Check Number Received b <br />EHD Staff: Date / / Account out: Date l�iLl <br />COMMENTS: <br />6u�i Invoice #: <br />CWO'lll, ULU as wn�Lw rW�abU "u <br />