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f <br /> I- QUIN COUNTY ENVIRONMENTAL HI Date run 5/17/2010 8:06:25AA SAN I . rH DEPARTMENT Report#5021 <br /> Run ty <br /> Facility Information as of 5/17/2010 Pagel <br /> Record Selection Criteria: Facility ID FA0018020 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> SSN!Fed Tax ID <br /> Owner ID OW0014797 New Owner ID <br /> Owner Name WASHINGTON, THORNELL JR <br /> Owner DBA SEPTIC BROTHERS <br /> Owner Address 922 COACH ST <br /> STOCKTON, CA 95209 <br /> Home Phone 209-957-2637 <br /> Work/Business Phone 209-329-0768 <br /> Mailing Address 922 COACH ST <br /> STOCKTON, CA 95209 <br /> Care of THORNELL WASHINGTON JR <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0018020 <br /> Facility Name SEPTIC BROTHERS <br /> Location 922 COACH ST <br /> STOCKTON, CA 95209 <br /> Phone 209-329-0768 xCELL <br /> Mailing Address 922 COACH ST <br /> STOCKTON, CA 95209 i <br /> Care of THORNELL WASHINGTON JR <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 003- BESTOLARIDES Fax <br /> APN 07224026 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name THORNELL WASHINGTON JR <br /> Title <br /> Day Phone 209-329-0768 Cell <br /> Night Phone 209-957-2637 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0031661 New Account ID <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name SEPTIC BROTHERS (Circle One) <br /> Account Balance as of 5/17/2010: $0.00 <br /> (Circle One) <br /> ProgramlElement and Desaiplion Record ID Employee ID and NameTransfer to Activellnactve <br /> Status New Owner? Delete <br /> 4244-PUMPER TRUCK PR0526620 EE0005944-MICHAEL ESCOTTO Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: i,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. 1also ce fy that all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: ` !7 <br /> Date <br /> Program Records to be TRANSFERED: '$20.00 Amount PaidDate 1 1 <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date / 1 <br /> Payment Type Check Number Received by <br /> REHS: Date Account out: Date--`�-1��I� <br /> COMMENTS: <br /> CCC C a SE FEZ-51' . <br /> 11eh-envlenvisionlreports15021.rpt <br />