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Date run 2/18/2015 4:02:37Ph SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Pagel <br /> Run by Facility Information as of 2/18/2015 <br /> Record Selection Criteria: Facility ID FA0022726 <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 OW0020470 New Owner ID <br /> Owner Name Bill 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 BIII Williams <br /> Location Code Alt Phone <br /> BOS 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 BIII Williams (Circle One) <br /> Account Balance as of 2/18/2015: $0.00 <br /> (Circle One) <br /> Transfer to Activeflnac e <br /> PrograMFlement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and'or project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also candy that all operations will be performed in accordance with all applicable Ordinance Codes anNor Standards and State anclor <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 I / <br /> Payment Type Check Number Received by <br /> REHS: Date / Account out: Date 2- fZ <br /> COMMENTS: <br />