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Date run 3/3/2016 9:58:29AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 3/3/2016 Pagel <br /> Record Selection Criteria: Facility ID FA0010621 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0008621 Case Number: H08424 New Owner ID <br /> Owner Name TERRILL, KEVIN S <br /> Owner DBA TERRILL TRANSPORTATION INC <br /> Owner Address 2459 MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-462-3322 <br /> Mailing Address 2459 MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0010621 10183683 <br /> Facility Name TERRILL TRANSPORTATION <br /> Location 2459 MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> Phone 209-462-3322 x <br /> Mailing Address 2459 MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> Care of terrill transportation <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 17130017 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017621 New Account ID: <br /> Mail Invoices to Account � � Mail Invoices to: Owner / Facility / Account <br /> Account Name TERRILLT CRT/'4JI1(?IV (Circle One) <br /> Account Balance as of 3/3/2016: 97.OIAJ� <br /> �"� (Circle One) <br /> PrograMElement and DescriptionTransfer to ActiveAnacNe <br /> Record ID Employee ID and Name Status <br /> New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0520817 EE0000006-HAZA SAEED Active Y N AD <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512909 EE00oo000-HAZ MAT SJC OES Inactive Y N A<25 TONS PERMIT PRO514388 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO610621 EEo000000-HAZ MAT SJC OES ofwive Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO528561 EE0001421 -STACY RIVERA Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0524084 EE0004486-ANGELICA SANDOVAL MARI Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532383 nye Y N Al D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ander 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: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / I <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment TypeCh ck Number Received by <br /> EHD Staff: Date �J / 8 / (O Account out: 14! L2 Date 'y/ -7 / 4, <br /> COMMENTS: <br /> Invoice#: <br />