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Dale run 3/3/2015 8:40:OOAM SAN JO/ 'IN COUNTY ENVIRONMENTAL HEAL' DEPARTMENT Repod#5021 <br /> Run by <br /> Facility Information as of 3/3/201 Pagel <br /> Record Selection Criteria: Facility ID FA0022726 <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 10 OW0020470 New Owner ID <br /> Owner Name BIII Williams <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-649-9894 <br /> Mailing Address 1111 E. Oak St. <br /> Stockton, Ca 95205 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022726 10482355 <br /> Facility Name Afforadable Fence Company <br /> Location 1111 E Oak St <br /> Stockton, CA 95205 <br /> Phone 209-948-4415 x <br /> Mailing Address 1111 E. Oak St. <br /> Stockton, Ca 95205 <br /> care of Bill Williams <br /> Location Code Alt Phone <br /> BOIS District Fax <br /> APN 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 AR0041632 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Afforadable Fence Company (Circle One) <br /> Account Balance as of 3/3/2015: $305.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Stews New Omer? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0539851 EE0000006-HAZA SAEED Active Y 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 associated with this facility <br /> or activity will be billed to the party,identified as the OWNER on this form. 1 also certify that all operations will be performed in accordance with all applicable Ortlinance Codes end'or Standards and State andor <br /> Federal Laws, <br /> APPLICANT'S SIGNATURE: Date /_I <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 /_I Account out: Date <br /> COMMENTS: <br />