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Date run 9/19/2014 11:23:43AI SAN X— JIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br />Run by - Pagel <br />Facility Information as of 9/19/2014 <br />Record Selection Criteria: Facility ID FA0005103 <br />OWNER FILE INFORMATION Number of facilities for this owner: <br />Owner ID <br />OW0003983 <br />Owner Name <br />Billy R Williams, Sr. <br />Owner DBA <br />AFFORDABLE FENCE COMPANY <br />Owner Address <br />1111 E OAK ST <br />Phone <br />STOCKTON, CA 95205-4421 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-824-4000 <br />Mailing Address <br />2004 E MARIPOSA RD <br />Location Code <br />STOCKTON, CA 95205 <br />Care of <br />001 - VILLAPUDUA <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0005103 10181733 <br />Facility Name <br />AFFORDABLE FENCE COMPANY <br />Location <br />2004 E MARIPOSA RD <br />STOCKTON, CA 95205 <br />Phone <br />209-948-4415 x <br />Mailing Address <br />2004 E. Mariposa Road <br />Stockton, CA 95205 <br />Care of <br />Billy R Williams, Sr. <br />Location Code <br />01-STOCKTON <br />BOS District <br />001 - VILLAPUDUA <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0005548 <br />Mail Invoices to Owner <br />Account Name Billy R Williams, Sr. <br />Account Balance as of 9/19/2014: $2,292.50 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID : <br />Site Mitigation Facility <br />Alt Phone <br />Fax <br />EMail : <br />Mail Invoices to <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <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 PR0530812 EE0000006 - HAZA SAEED Active Y N A (�6 D <br />2381 - UST FACILITY (BEFORE 1/84) - obsolete PR0501442 EE0000008 - LETITIA BRIGGS Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0533905 Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andtor project specific, PHS/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 all applicable Ordinance Codes and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE:Yf �fC Dated/ \� / <br />Program Records to be TRANSSFERED: * $25.00 = Amount Paid Date <br />Water System to be TRANSFERED: Amount Paid Date <br />Payment Type Check Number Receiv <br />REHS: Date / / Account out: Date / / <br />COMMENTS: <br />