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Date run 2/25/2013 11:32:15A1 SAN J IN COUNTY ENVIRONMENTAL HEA DEPARTMENT <br /> Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/25/2013 <br /> Record 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 f ZCrt-A-B-AME-Rte-AN-RtJBBE4R--GCH+4G— CSI w z <br /> Owner DBA <br /> Owner Address 8830 W LINNE RD CD O <br /> TRACY, CA 95304 N rl �J J <br /> Home Phone Not Specified <br /> Work/Business Phone 209-836-0965 LO 2 g10 " O D <br /> Mailing Address PO BOX 450 O Pb 0?< CJF 10 z`t I _ <br /> TRACY, CA 953780450 t�1 P ly PJe��a til � � <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 Invoices to 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 /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0519520 EE0002474-MICHAEL PARISSI Active N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0507056 EE0002646-THUY TRAN Active IY5 N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOPPRO511577 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 N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project s 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 certify that all operations will be performed in accordance with plica rdinance Cod7and/or Standards and State an or <br /> Federal Laws. ►J <br /> t.%A <br /> APPLICANTS SIGNATURE: Date o�l a�� '�� , <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / / � ) <br /> Water System to be TRANSFERED: Amount Paid Date / / 3 r�/2 <br /> Payment Type _ Check Number Receiv / :J <br /> REH : ate A Account out: P==21Date / / <br /> COMMENTS: � � <br />