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Date nr� 2/2/2009 9:32:06AM SAN JOA U� <br /> r un by - Q ' ZOUNTY ENVIRONMENTAL HEALTH <br /> y ARTMENT Report*5021 <br /> Facility Information as of 2/2/2009 Pagel <br /> Record Selection Criteria: Facility ID <br /> FA0416053 <br /> Make changeslcorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> Owner ID OWO FILE SSN/Fed Tax ID : <br /> 012964 New Owner ID : t <br /> Owner Name CAUSE, KEVIN J j <br /> Owner DBA <br /> Owner Address 2045 CHEYENNE RD ; <br /> COPPEROPOLIS, CA 95228 <br /> Home Phone 209-785-6163 <br /> Work/Business Phone <br /> Not Specified <br /> Mailing Address PO BOX 702 <br /> 5'^ <br /> COPPEROPOLIS, CA 95228 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0016053 <br /> Facility Name FOOTHILL SANITARY <br /> Location 33 COPPER COVE ST <br /> COPPEROPOLIS, CA 95228 <br /> Phone 209-785-6163 <br /> Mailing Address PO BOX 702 <br /> 1 COPPEROPOLIS, CA 95228 <br /> 1. <br /> Care of GAUSE, KEVIN J <br /> Location Code 9$- OUT OF COUNTY Alt Phone <br /> BOS District Fax <br /> APN EMail: ''��\'�jAvtc�Cl�,iFL_ .Cp t'tA'. <br /> l <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name KEVIN J GAUSE <br /> Title <br /> Day Phone 209-785-6163 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0027995 New Account ID <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility I Account <br /> Account Name FOOTHILL SANITARY (circle one) <br /> Account Balance as of 21212009: $0.00 i <br /> (Circle One) <br /> Transferto Activellnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete i <br /> 4244-PUMPER TRUCK - PRO523835 EE0005944-MICHAEL ESCOTTO A Ive Y N A I D <br /> BILLING and COMPLIANCE ACK OWLEDGEMEN I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSlEHD hourly charges associated with this <br /> facility or activity will be billed to the arty identified as a OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinate Codes and for Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE! :Date 1 0 /eD <br /> Program Records to be TRANSFERED: 20 0= Amount Paid_ 0 A Date � 11 0 <br /> Water System to be TRANSFERED: '$372.00= Amount Paid ' Date 1 I <br /> Payment Type Check Number 5 Received b V V _ <br /> I <br /> REHS: Date / ! Account out: Date g-'1 1 Of <br /> COMMENTS: <br /> I <br /> 11eh-envlenvisionlreports15021.rpt <br />