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Data run 6/7/2013 10:07:15AM SAN JOA !N COUNTY ENVIRONMENTAL HEAL' DIEPARTMENT Report#5021 <br /> Run by �.L <br /> Facility Information as of 6/7/2013 Pagel <br /> Record Selection Criteria: Facility ID FA0019303 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0015845 New Owner ID <br /> Owner Name PATRICK W MAPLE <br /> Owner DBA ROOF RANGERS <br /> Owner Address 129 HOOPER DR <br /> STOCKTON, CA 95203 I <br /> Home Phone Not Specified <br /> Work/Business Phone 209-745-5753 t <br /> Mailing Address PO BOX 5114 <br /> GALT, CA 95632 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0019303 10,187,189 <br /> Facility Name ROOF RANGERS <br /> Location 129 HOOPER DR <br /> STOCKTON, CA 95203 <br /> Phone 209-745-5753 x0 <br /> Mailing Address PO BOX 5114 <br /> GALT, CA 95632 <br /> Care of <br /> Location Code All Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 16203007 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 AR0034317 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name PATRICK W MAPLE (Circle One) <br /> Account Balance as of 6/7/2013: $1,692.00 <br /> (Circle One) <br /> Transfer to ActivMnactve <br /> Progra"Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO528740 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO531710 Inas vc V N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly charges associatedwith this facility <br /> or activity will be billed to the party identified as the OWNER on this form l also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and Slate andor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> ment Ty p Check Number Recei�vle�d�b <br /> RE O Z Date / 11 / Account out: Data 6P 12— <br /> COMM NTS: <br /> Ufa �a <br /> //V <br /> RID <br />