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Date run 5/5/2010 1:54:08PM SAN JUIN COUNTY ENVIRONMENTAL HEAW DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as o'r 5/5/2010 <br /> Record Selection Criteria: Facility ID FA0004495 <br /> +� Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) 4DAa W/0 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0003410 New Owner ID <br /> Owner Name RO LAB AMERICAN RUBBER CO INC <br /> Owner DBA RO-LAB AMERICAN RUBBER CO INC <br /> Owner Address 8830 W LINNE RD <br /> TRACY, CA 95376 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-836-0965 <br /> Mailing Address PO BOX 450 <br /> TRACY, CA 953780450 <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 A Alt Phone <br /> BOS District 005 - ORNELLAS, LEROY Fax R Oct -U q� S <br /> APN 25321006 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title h <br /> Day Phone '! _ 6 —0 s <br /> Night Phone 9 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004177 New <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 5/5/2010: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0507056 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOtPR0511577 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0519520 EE0000000-HAZ MAT SJC OES Active Y N A 1 D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARf'R0507057 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0534397 Active Y N A I D <br /> 4630-NTNC WATER SYSTEM WA0461338 EE0005838-ADRIENNE ELLSAESSEActive Y 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 specific,PHS/EHD hourly charges associated with this <br /> 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: 1",7 Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: `$372.00= Amount Paid Date <br /> Payment Type-..... Check Number Receiv <br /> REHS. Date Account out: Date / // / /o <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />