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Date run 11/1/2010 8:21:09AN SAN.RUIN COUNTY ENVIRONMENTAL HEI H DEPARTMENT - Regori#5021 <br /> Run by— {`. ' '.9 Pagel <br /> Facility Information as of 11/1/2010 <br /> Record Selection tlriferia: Facility 0 -FA0018020 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN 1 Fed Tax ID <br /> Owner ID OW0014797 New Owner ID <br /> Owner Name WASHINGTON, THORNELL JR <br /> Owner DBA SEPTIC BROTHERS <br /> I Owner Address 922 COACH ST <br /> STOCKTON, CA 95209 <br /> Home Phone 209-957-2637 <br /> Work/Business Phone 209-329-0768 <br /> I Mailing Address 922 COACH ST <br /> STOCKTON, CA 95209 <br /> Care of THORNELL WASHINGTON JR <br /> FACILITY FILE INFORMATION <br /> Facility 1D 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 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 1 Facility 1 Account <br /> Account Name SEPTIC BROTHERS (Circle One) <br /> Account Balance as of 111112010: $0.00 <br /> (Circle One) <br /> Transferto Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4244-PUMPER TRUCK PRO526620 EE0005944-MICHAEL ESCOTTO Active Y N A 1 D <br /> 4244-PUMPER TRUCK <ZP EE0005944-MICHAEL ESCOTTO Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSIEHD hourly charges associated with this <br /> facility or activity will be billed to the parry identified as the OWNER on this form, t also certify that all operations will be performed in accordance with all applicable Ordinace Codes and for Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: bate ! / <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date / 1 <br /> Water System to be TRANSFERED: Amount Paid Date I I <br /> Payment Type Check Number Received by <br /> RENS: Date 1 1 Account out: Date 1 1 <br /> COMMENTS: <br /> 11eh-en vlenvisionlreports15021.rpt <br />