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Date run 2/3/2017 9:28:01AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Run by Report x5021 <br /> Facility Information as of 2/3/2017 Pagel <br /> Record Selection Criteria: Facility ID FA0017288 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 <br /> SSN/Fed Tax ID <br /> Owner ID OW0014129 New Owner ID <br /> Owner Name WILLIAM SARALE <br /> Owner DBA WILLIAM SARALE <br /> Owner Address 14600 E EIGHT MILE RD <br /> LINDEN, CA 95236 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-470-0747 <br /> Mailing Address PO BOX 7960 <br /> STOCKTON, CA 95267 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017288 10186217 <br /> Facility Name WILLIAM SARALE <br /> Location 14600 E EIGHT MILE RD <br /> LINDEN, CA 95236 <br /> Phone 209-470-0747 X <br /> Mailing Address PO BOX 7960 <br /> STOCKTON, CA 95267 <br /> Care of William Sarale <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 09101008 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title �✓ I L u <br /> r-� <br /> Day Phone ILI�'ul 9)411YA <br /> 9-41 K ^<F 5'k�.0 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION FEB 0 3 2017 <br /> Account ID AR0030170 'ENVIRONMENTAL HEALTH NewAcoount ID: <br /> Mail Invoices to Account PERMIT/SERVICES Mail Invoices to: Owner / Facility / Account <br /> Account Name WILLIAM SARALE (ClydeOne) <br /> Account Balance as of 2/3/2017: $306.00 <br /> (Circle One) <br /> Transfer to ActiveArachns <br /> Program/Element and Description Record ID Employee ID antl Name stews New Ovme/I Delete <br /> 1958-HM-Farm Operations PRO525473 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0530384 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRG530383 EE0000006-HAZA SAEED Inactive Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO531890 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acimowledge that all site,ands project speclgc.PHSIEHD hourly charges associated win this facility <br /> a activity will be billed to the party identRed as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ardor <br /> Fetlerel Le�w�a. LU�[,,��' /1 <br /> APPLICANTS SIGDNATURE: �� �D�� � ��'�'"•�" <br /> Date _/_/_ <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: M AkN 7-lti Date Account out:�_ Date <br /> COMMENTS: <br /> Invoice* <br />