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Date run 12/21/2010 8:58:56AI SAN J( )UIN COUNTY ENVIRONMENTAL HE/ 'H DEPARTMENT Report#W21 <br /> Run by Nod <br /> Pagel <br /> Facility Information as of 12/21/2010 <br /> Record Selection Criteria: Facility ID FA0015391 <br /> Make changesicorrections in RED ink. <br /> C NFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION '-� SSN 1 Fed Tax ID <br /> Owner ID OW0012357 New Owner ID <br /> Owner Name GARCIA, RAY& BERTHA <br /> Owner DBAA_SEP�IG 6f-Fk to <br /> Owner Address 217 MADERA AVE <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 CE <br /> Location <br /> MODESTO, CA 95351 <br /> Phone 249-238-3986 <br /> Mailing Address PO BOX 581170 <br /> MODESTO, CA 953580021 <br /> Care of RAY& BERTHA GARCIA <br /> Location Code 98- OUT OF COUNTY Alt Phone <br /> BOS District 000- Unknown 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 1 Facility I Account <br /> Account Name E +,,� � S eNV% (Cirdeone) <br /> Account Balance as of 1212112010: $158.00 <br /> (Circle One) <br /> Transfer to Adivellnedve <br /> Program/Element and Description Record 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 PRO522593 EE0004045-TED TASIOPOULOS Inactive Y N A I D <br /> 4244-PUMPER TRUCK PR0526864 EE0004045-TED TASIOPOULOS 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 wish this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received b <br /> RENS: _rj u��.�n.� ��r Date 1�-1 17 ! & Account out: Dated [ 1 �D <br /> COMMENTS: <br /> �' <br /> 11eh-envlenvisionVeports15021.rpt <br />