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Dale ran 2/25/2013 11:32:15AI SAN JO UIN COUNTY ENVIRONMENTAL HEAT T DEPARTMENT Report#5021 <br /> Run by g <br /> ..r Facility Information as of 2/25/2013 Pagel <br /> Recon)Selection Criteria: Facility ID FA0004495 <br /> Make changes/corrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) 2 <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0003410 New Owner ID <br /> Owner Name <br /> 0 <br /> Owner DBA <br /> Owner Address 8830 W LINNE RD O O <br /> TRACY, CA 95304 -e C�5;J <br /> Home Phone Not Specified <br /> Work/Business Phone 209-836-0965 0 O <br /> Mailing Address PO BOX 450 O P-)ox 'Z�r I C7� <br /> TRACY, CA 953780450 tJk LL) PJ2Y-L/Vl IE) <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0004495 <br /> Facility Name RO LAB AMERICAN RUBBER CO <br /> Location 8830 W LINNE RD <br /> TRACY, CA 95304 <br /> Phone 209-836-0965 <br /> Mailing Address PO BOX 450 <br /> TRACY, CA 953780450 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 005 -ORNELLAS, LEROY Fax <br /> APN 25321006 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 AR0004177 New Account ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name RO LAB AMERICAN RUBBER CO (Circle One) <br /> Account Balance as of 2/25/2013: $698.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Progra"Element and Description Record ID Employee ID and Name Sal New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO519520 EE0002474-MICHAEL PARISSI Active N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0507056 EE0002646-THUY TRAN Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOPPR0511577 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0507057 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0534397 Inactive N A I D <br /> 4630-NTNC WATER SYSTEM WA0461338 EE0005838-ADRIENNE ELLSAESSEActive 4 N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andor projects HS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form I also cenify that all operations will be performed in accortlence with pL mance Cod andor Sbmdardsand Slatean r <br /> Federal Lews. � 1 r/7 <br /> APPLICANT'S SIGNATURE: Te-jn T/ <br /> - e-/'j2Y7��l7�G Date �/�/� jyu A.E, <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date A <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Recei <br /> REH ate "R Account out: Date / /� <br /> COMMENTS: �r -Z 1�� I <br />