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Data Rm 6/28/2013 9:02:32Ah SAN JF UIN COUNTY ENVIRONMENTAL HE,' J DEPARTMENT Report x5021 Run by �I Pagel Facility Information as of 6/28/2013 Record Selection Criteria: Facility ID FA0004518 Make changes/corrections ink. INFORMATION CHANGE(date) I OWNERSHIP CHANGE(date) OWNER FILE INFORMATION SSN/Fed Tax ID Owner ID OW0000482 New Owner ID Owner Name SJC PUBLIC WORKS Owner DBA SJC PUBLIC WORKS Owner Address 1810 E HAZELTON AVE STOCKTON, CA 95205 Home Phone 209-468-3031 Work/Business Phone 209-948-1345 Mailing Address PO BOX 1810 STOCKTON, CA 95201 Care of GORTON, DAVID FACILITY FILE INFORMATION Facility lD/CERS ID FA0004518 10,181,651 Facility Name NORTH COUNTY LANDFILL Location 17720 E HARNEY LN LODI, CA 95240 Phone 209-468-3066 Mailing Address PO BOX 1810 STOCKTON, CA 95201 Care of PUBLIC WORKS DEPARTMENT Location Code 99- UNINCORPORATED P Alt Phone BOS District 004 -VOGEL, KEN Fax APN 06512004 Entail: EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0004201 New Account ID. Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account Account Name NORTH COUNTY LANDFILL (Circle One) Account Balance as of 6/28/2013: $7,696.00 (Circle One) Transfer to ActweAnactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1921 -HMBP-Regular-Primary Location PR0512560 EE0008709-JAMIE DE LA ROSA Active Y N A I D 2217-APPLIANCE RECYCLER PRO523556 EE0001422-ARIS CACAPIT Active Y N A I D 2218-CRT HANDLER PRO518299 EE0001422-ARIS CACAPIT Active Y N A I D 2220-SM HW GEN<5 TONS/YR PRO523369 EE0001422-ARIS CACAPIT Active Y N A I D 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO510272 EE0000000-HAZ MAT SJC DES InadivE Y N A I D 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PRO523381 EE0001422-ARIS CACAPIT Active,l Y N A I D 4433-LANDFILL DISPOSAL SITE PR0440058 EE0003973-ROBERT MCCLELLON Active Y N A I D 4740-WASTE TIRE SITE-EXEMPT PRO523816 EE0004680-NATALIA SUBBOTNIKOVA Active Y N A I D ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532219 Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHSIEHD hourly charges associated with this facility or activity will be billed to the party identified as the OWNER on this form I also candy that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and Stale ander Federal Laws. Gfn��ta��IS APPLICANTS SIGNATURE: Date I / Program Records to be TRANSFERED: '$25.00= Amount Paid Date Water System to be TRANSFERED: Amount Paid Date / / Payment rrT��ype �,Check Number Race d REHS: �L-�-�yw�—k�trt o Dater/ / Account out: Date_ /1� COMMENrs: