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ewe" 12/14/2012 2:53:30P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report7t9021 <br /> Run by Paget <br /> Facility Information as of 12114/2012 <br /> Record Selection Criteria: Facility ID FA0015391 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0012357 New Owner ID <br /> Owner Name GARCIA, RAY& BERTHA <br /> Owner DBA A& R SEPTIC SERVICE <br /> Owner Address 217MADERAAVE <br /> MODESTO, CA 95351 <br /> Home Phone 209-238-3986 <br /> WorkBusiness Phone Not Specified <br /> Mailing Address 217 MADERA AVE <br /> MODESTO, CA 95351 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015391 <br /> Facility Name A& R SEPTIC SERVICE <br /> Location 4221 CROWS LANDING RD STE 100 <br /> MODESTO, CA 95351 <br /> Phone 209-238-3986 <br /> Mailing Address PO BOX 581170 A �_ <br /> MODESTO, CA 953580021 <br /> Care of RAY& BERTHA GARCIA <br /> Location Code 98-OUT OF COUNTY Alt Phone <br /> BOS District 000- UNKNOWN OR OUT OF COUNTY Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name RAY GARCIA/BERTHA GARCIA <br /> Title <br /> Day Phone 209-238-3986 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026516 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name A& R SEPTIC SERVICE Carole One) <br /> Account Balance as of 12114/2012: $158.00 <br /> (Circle One) <br /> Transfer to ACUv&mactve <br /> PrograWELment and Description Recon!ID Employee ID and Name Status New Owner? Delete <br /> 4244-PUMPER TRUCK PRO522592 EE0004045-TED TASIOPOULOS Inactive Y N A I D <br /> 4244-PUMPER TRUCK PR0522593 EE0004045-TED TASIOPOULOS Inactive Y N A I D <br /> 4244-PUMPER TRUCK PRO526864 EE0004045-TED TASIOPOULOS Active Y N A D <br /> 4246-PUMPER YARD PR0536471 EE0004045-TED TASIOPOULOS Active,Exemot Y N A I D <br /> BILLING and COMPLIANCE ACI<NOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the parry identfied as the OWNER on this form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and State ands <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 <br /> Payment' Check�Num7ber i Received by <br /> Lf�3 Date /��1 -7 —ZZ. Account out: <br /> �{/ _ Date� <br /> COMMEMS: ^/� 710 �I1 q.L% "i �/RY>l t .{1—&.& ""//� <br />