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Date run 126/2010 2:01:43PN SAN JOAQ1 COUNTY ENVIRONMENTAL HEALTH -PARTMENT Report#5021 <br /> Run 6y Pagel <br /> Facility Information as of 12/6/2010 �'` <br /> Record Selection Criteria: Facility ID FA0015391 <br /> Make changesicorrections 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 GARCIA SEPTIC SERVICE <br /> Owner Address 217 MADERA AVE <br /> MODESTO, CA 95351 <br /> Home Phone 209-238-3986 <br /> Work/Business 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 GARCIA SEPTIC SERVICE <br /> Location 322 W RIVER RD STE 100 <br /> MODESTO, CA 95351 <br /> Phone 209-238-3986 <br /> Mailing Address 822-W RIVER <br /> oo STE <br /> MODESTO, CA %861 g 5 3 S$ — p b 2- <br /> Care <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 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name GARCIA SEPTIC SERVICE (Circle One) <br /> Account Balance as of 121612010: $158.00 <br /> (Circle One) <br /> Transfer to Activellnac1ve <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 PR0522593 EE0004045-TED TASIOPOULOS Inactive Y N A I D <br /> 4244-PUMPER TRUCK PRO526864 EE0004045-TED TASIOPOULOS Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT; [,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 party identified as the OWNER on this form. I also certify that alt operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. ,, Q <br /> APPLICANT'S SIGNATURE: 5-e-e- CIe,\ �` ' '"'`�'�"" Date k2! <br /> Program Records to be TRANSFERED: $25.00= Amount Paid Date / ! <br /> Water System-to be TRANSFERED: Amount Paid Date ! ! <br /> Payment Type Check Number ,�,._ _ Received by <br /> RENS: Date 1 I Account out: � Date kZllo !\ I) <br /> COMMENTS: <br /> lleh-envlen visionlreports15021.rpt <br />