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Date run 1/29/2013 11:39:21 Al SAN J UIN COUNTY ENVIRONMENTAL HEA Report#5021 <br /> DEPARTMENT Pagel <br /> Run by <br /> Facility Information as of 1/29/2013 <br /> Record Selection Criteria: Facility ID FA0010287 <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 OW0008287 Case Number: 7614 New Owner ID <br /> Owner Name BRITZ-SIMPLOT GROWER SOLUTIONS <br /> Owner DBA BRITZ-SIMPLOT GROWER SOLUTIONS <br /> Owner Address 3265 W FIGARDEN DR <br /> FRESNO, CA 937113906 <br /> Home Phone Not Specified <br /> Work/Business Phone 559-448-8000 <br /> Mailing Address PO BOX 60011 <br /> FRESNO, CA 937940011 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010287 <br /> Facility Name BRITZ-SIMPLOT GROWER SOLUTIONS LLC <br /> Location 7707 S JACK TONE RD <br /> STOCKTON, CA 95215 <br /> Phone 209-461-6565 x0 <br /> Mailing Address PO BOX 60011 Q 0`50 <br /> FRESNO, CA 937940011 TrAlhflO i CA Q X(1 (10 51) <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 005-ORNELLAS, LEROY Fax <br /> APN 18117004 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017287 New Account ID: <br /> Maillnvoicesto Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name BRITZ-SIMPLOT GROWER SOLUTIONS (Circle One) <br /> Account Balance as of 1/29/2013: $0.00 <br /> (Circle One) <br /> Transfer to Active/lnactve <br /> Pro ranvElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 HMBP-Regular-Primary Location PR0521774 EE0006044-LOWELL ALLEN Active Y N A I D <br /> -CaIARP PROGRAM 2 FACILITY PRO530018 EE0000988-KASEY FOLEY Active Y N A I D <br /> 1995-CalARP FAC STATE SURCHARGE FEE PRO522226 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIIPR0512575 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2226-CaIARP PROGRAM PR0514757 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0510287 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO530758 EE0007379-AMANDA BOERTIEN Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPR0533842 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andvor project specific.PHSIEHD hourly charges 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 andor Standards and State ancvor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date_/_/_ <br /> Payment T�e � Check Number Re ed b <br /> REHS: Date /L ^/ Account out: Date=/=7-0-/43- <br /> COMMENTS: <br />