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Date run 9/13/2012 2:34:08PR SAN J IN COUNTY ENVIRONMENTAL HEA.4 DEPARTMENT Report #5021 <br />Run by <br />Facility Information as of 9/13/2012 Pagel <br />Record Selection Criteria: Facility ID FA0007696 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0006357 <br />Owner Name <br />NEWARK GROUP INDUSTRIES <br />Owner DBA <br />RECYCLED FIBERS <br />Owner Address <br />2575 GRAND CANAL BLVD STE 202 <br />Phone <br />STOCKTON, CA 952078250 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-464-6590 <br />Mailing Address <br />2575 GRAND CANAL BLVD STE 202 <br />STOCKTON, CA 952078250 <br />Care of <br />Water System to be TRANSFERED: <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0007696 <br />Facility Name <br />RECYCLED FIBERS <br />Location <br />800 W CHURCH ST <br />2399 - UNIFIED PROGRAM FAC STATE SURCHAR(PR0507053 EE0000418 - MICHAEL KITH Inactive Y N A I D <br />STOCKTON, CA 95203 <br />Phone <br />209-464-6590 <br />Mailing Address <br />2575 GRAND CANAL BLVD STE 202 <br />ensCJ , Oupl fcqP�j F A <br />STOCKTON, CA 952078250 <br />Care of <br />Location Code 01 -STOCKTON <br />BOS District 001 - VILLAPUDUA <br />APN 14523004 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) ' Z <br />OWNERSHIP CHANGE (date) _ <br />SSN/ Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0013293 <br />Mailinvoicesto Facility Mail Invoices to: <br />Account Name RECYCLED FIBERS <br />Account Balance as of 9/13/2012: $0.00 <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />PrograMElement and Description <br />Transfer to ActivWInactve <br />Record ID Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Regular-Primary Location <br />PRO524662 EE0009817- ROBERT LOPEZ Active Y N A Uf D <br />2227 - GEN 5<25 TONS PERMIT <br />PRO507052 EE0000418 - MICHAEL KITH Inactive Y N A i D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHAR(PR0507053 EE0000418 - MICHAEL KITH Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCKPRO533356 Active Y N A 0 D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned <br />owner, operator or agent of same, acknowledge that all site, anclor project specific, PHSIEHD hourly charges associated with this reality <br />or activity will be billed to the party identifed as the OWNER on this farm I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andror standards and State and'or <br />Federal Laws. <br />p(v ryc, <br />ensCJ , Oupl fcqP�j F A <br />APPLICANTS SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: <br />* $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: <br />Amount Paid Date <br />l� O �0 'l '11 <br />Payment nTy pe Check Number <br />REHS: IS.�./--�� '`J <br />r� <br />Date �/ /I Recei Account out: _ Date / /�. <br />COMMENTS: <br />