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Date run 12/9/2015 1:36:34PR SAN JUIN COUNTY ENVERONMENTAL HEA* DEPARTMENT Report #5021 Run by Paget Facility Information as of 12/9/2015 Record Selection Criteria: Facility ID FA0013569 OWNER FILE INFORMATION Number of facilities for this owner: 1 Owner ID OW0010689 Owner Name Thomas Asbury Owner DBA SUMMIT ROOFING SERVICES Owner Address 3131 BAY MEADOWS CT Phone LIVERMORE, CA 94550 Home Phone Not Specified Work/Business Phone 510-453-8468 Mailing Address 3131 Bay Meadows Ct Location Code Livermore, CA 94550 Care of 005 - ELLIOTT, BOB FACILITY FILE INFORMATION Facility lD/CERS ID FA0013569 10184415 Facility Name SUMMIT ROOFING SERVICES Location 705 INDUSTRIAL PARK (Circle One) MANTECA, CA 95337-6115 Phone 209-825-3042 x Mailing Address 705 INDUSTRIAL PARK DR MANTECA, CA 95337-6115 Care of Summit Roofing Services Location Code 04 - MANTECA BOS District 005 - ELLIOTT, BOB APN 22119011 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0022678 Mail Invoices to Account Account Name SUMMIT ROOFING SERVICES Account Balance as of 12/9/2015: $0.00 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN /Fed Tax ID : New Owner ID : Fax EMail : Mail Invoices to: New Account ID: : Owner / Facility / Account (Circle One) APPLICANTS SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff:��E COMMENTS: Date I/ $25.00 = Amount Paid Date Amount Paid Date Received by i Date // Account out: Date 1 y// / S I v'vv 1�(�5;ktz v�slf �d� Invoice #: (Circle One) drngraMElement Transfer to ActiveAnactve and Description Record ID Employee ID and Name Status New Owner? Delete 921 -- HMBP-Reqular-Primary Location PR0521088 EE0000010 - PETER LOMBARDI Active Y N A I D �1SM HW GEN <5 TONSNR PRO540612 EE0009001 - ELENA MANZO Active Y N A I D 224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0517725 EE0000000 - HAZ MAT SJC GIES Inactive Y N A I D 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0517726 EE0009903 - DOUG WILSON Inactive Y N A 1 D ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0532087 Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, anNor 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 certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State anclor Federal Laws. APPLICANTS SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff:��E COMMENTS: Date I/ $25.00 = Amount Paid Date Amount Paid Date Received by i Date // Account out: Date 1 y// / S I v'vv 1�(�5;ktz v�slf �d� Invoice #: