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Date run 3/10/2015 11:36:11AI SAN JO?'-'UIN COUNTY ENVIRONMENTAL HEAL' -'DEPARTMENT Report#5021 <br /> Run by Papal <br /> Facility Information as of 3/10/201 <br /> Record Selection Criteria: Facility ID FA0010621 <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 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 209-931-5410 <br /> Mailing Address 2459 MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0010621 10183683 <br /> Facility Name TERRILL TRANSPORTATION <br /> Location 2459 MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> Phone 209-462-3322 <br /> Mailing Address 2459 MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 17130017 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 AR0017621 NevvAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name TERRILL, KEVIN S (Circle One) <br /> Account Balance as of 3/10/2015: $2,037.00 <br /> (Code One) <br /> Transfer to Active/Inecive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0520817 EE0000006-HAZA SAEED Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO512909 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2227-GEN 5<25 TONS PERMIT PR0514388 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO510621 EE0000000-HAZ MAT SJC DES Inactive 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 EE0002622-BENJAMIN ESCOTTO Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532383 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowletlge that all site,anNor project specific,PHSEHO hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this forth. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State anNor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: 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 /> REHS: Date_/ / Account out: Date <br /> COMMENTS', <br />