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Dale run 1/10/2013 3:22'.32PR SAN JCS iUIN COUNTY ENVIRONMENTAL HEA 'I DEPARTMENT Report#5021 <br /> Run by v Pagel <br /> Facility Information as of 1/10/2013 <br /> Record Selection Criteria. Facility ID FA0010407 <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 OW0008407 Case Number: H08030 New Owner ID <br /> Owner Name ENCON PACIFIC LLC <br /> Owner DBA CONCRETE PRODUCTS OF NORTHERN <br /> Owner Address 1660 LINCOLN ST STE 1800 <br /> DENVER, CO 802643103 <br /> Home Phone Not Specified <br /> Work/Business Phone 303-298-1900 _ <br /> Mailing Address 1660 LINCOLN ST STE#1800 eV <br /> DENVER, CO 802643103 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010407 <br /> Facility Name CONCRETE PRODUCTS OF NO CA <br /> Location 26901 HANSEN RD <br /> TRACY, CA 95376 <br /> Phone 209-836-3125 x0 <br /> Mailing Address 1660 LINCOLN ST STE#1800 <br /> DENVER, CO 802643103 <br /> Care of <br /> Location Code 99 - UNINCORPORATED.4 Alt Phone <br /> BOS District 005-ORNELLAS, LEROY Fax <br /> APN 20911010 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017407 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name ENCON PACIFIC LLC (CkaeOoe) <br /> Account Balance as of 1/10/2013: $0.00 <br /> (Circle One) <br /> Transfer to Activelfnaclve <br /> Pr a%Element and Description Record ID Employee M and Name Status New Owner? Delete <br /> 1 MBP-Regular-Primary Location PRO520336 EE0002474-MICHAEL PARISSI Active Y N A D <br /> 192 <br /> 4-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0512695 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0510407 EEO000000-HAZ MAT SJC DES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0532908 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges associated!with Nis facility <br /> or activity will be billed to the party identified as the OWNER on Nis form, I also carry that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State ands <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 Received by <br /> REHS: yDate <br /> � / �`�/D!1_ Account out: y Date_/ / <br /> COMMENT'Ir f1� ^n� !v 1 "1"Ci 9 � ✓'1/�/ f� �I^/1 I�/�//J� l <br /> V�.1/ 1— <br />