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Date run 8/17/2011 8:50:40AN SAN JUIN COUNTY ENVIRONMENTAL HE DEPARTMENT Report #5021 Run by Pagel Facility Information as of 8/17/2 Record Selection Criteria: Facility ID FA0007696 OWNER FILE INFORMATION Owner ID OW0006357 Owner Name NEWARK GROUP INDUSTRIES Owner DBA RECYCLED FIBERS Owner Address 2575 GRAND CANAL BLVD STE 202 Phone STOCKTON, CA 952078250 Home Phone Not Specified Work/Business Phone 209-464-6590 Mailing Address 2575 GRAND CANAL BLVD STE 202 2244 -PACT TRANSFER RECORD - IDES PRO524662 STOCKTON, CA 952078250 Care of A (C—I) D FACILITY FILE INFORMATION Facility ID FA0007696 Facility Name RECYCLED FIBERS Location 800 W CHURCH ST Transfer to STOCKTON, CA 95203 Phone 209464-6590 Mailing Address 2575 GRAND CANAL BLVD STE 202 STOCKTON, CA 952078250 Care of Location Code 01 - STOCKTON BOS District 001 - VILLAPUDUA APN EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone 209-464-3406 Night Phone 209-464-3406 ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0013293 Mail Invoices to Facility Account Name RECYCLED FIBERS Account Balance as of 8/17/2011: $0.00 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail : New Account ID: : Mail Invoices to: Owner / Facility / Account (Circle One) APPLICANTS SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number REHS: COMMENTS \\eh-env\envision\reports\5021.rpt $25.00 = Date / Date Amount Paid Date _ Amount Paid ate Re i _ Account out: Date 7 / (Circle One) Transfer to Active/Inectve Program/Element and Description Retard ID Employee ID and Name Status New Owner? Delete 2227 - GEN 5<25 TONS PERMIT PR0507052 EE0000418- MICHAEL KITH Inactive Y N A I D 2244 -PACT TRANSFER RECORD - IDES PRO524662 Active Y N A (C—I) D 2399 - UNIFIED PROGRAM FAC STATE SURCHARPR0507053 EE0000418 - MICHAEL KITH Inactive Y N A D ERSC - ELECTRONIC REPORTING STATE SURCHPR0533356 Active Y N A D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility 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 Ordinate Codes and/or Standards and State and/or Federal Laws. APPLICANTS SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number REHS: COMMENTS \\eh-env\envision\reports\5021.rpt $25.00 = Date / Date Amount Paid Date _ Amount Paid ate Re i _ Account out: Date 7 /