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Date run 11/24/2015 3:58:15F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 11/24/2015 <br /> Record Selection Criteria: Facility ID FA0018020 <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 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/CERS 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 <br /> Care of THORNELL WASHINGTON JR <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 003- BESTOLARIDES, STEVE Fax <br /> APN 07224026 EMail: <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 / Facility / Account <br /> Account Name SEPTIC BROTHERS (Circle One) <br /> Account Balance as of 11/24/2015: $474.00 <br /> (Circle One) <br /> Transfer to ActiveMach e <br /> ProgrartJElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4244-PUMPER TRUCK pk, PRO526620 EE0005944-MICHAEL ESCOTTO Active Y N A I D <br /> 4244-PUMPER TRUCK —p PRO535146 - EE0005944-MICHAEL ESCOTTO Active Y N A Q D <br /> 4244-PUMPER TRUCK oy,PRO540431 EE0005944-MICHAEL ESCOTTO Active Y N A I D <br /> 4246-PUMPER YARD PRO536489 EE0005944-MICHAEL ESCOTTO Active,I Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,acknowledge that all site,ani project spec,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this forth. I also[artily that all operations will be performed in accordance with all applicable Ordinance Codes anNor Standards and State anG'or <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 Ty '� er Received b <br /> EHD Sta Date / � / /S Account out: Date,�L/ 30 /11� <br /> COMMENTS: <br /> 1�GJf/ lll.�fG�/�W Invoice#: <br />