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- Report#5027 I. <br /> Date run 5/13/2009 9:07:03AM SAN J7 �`?UIN COU NTY'ENVIRONMENTAL HE,' CH DEPARTMENT <br /> Run by Paget <br /> Facility Information as of 5/13/2009 ! <br /> Record Selection Criteria: Facility ID FA0015391 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) 5 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN I Fed Tax ID <br /> Owner ID OW 0012357 New Owner ID,: <br /> i <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 /> t Mailing Address 217 MADERA AVE <br /> MODESTO, CA 95351 <br /> Care of p <br /> FACILITY FILE INFORMATION <br /> I I <br /> Facility ID FA0015391 <br /> Facility Name GARCIA PTIC SERVICE <br /> ' LocationR RD 3 l IZ 1tx� <br /> 71V <br /> TO, CA 95351 AAv S 5 <br /> Phone 3 -3986 <br /> Mailing Address ER RDS <br /> MODESTO, CA 95351 <br /> :. Cam of RAY& BERTHA GARCIA <br /> Location Code 98- OUT OF COUNTY Alt Phone <br /> BOS District 000- Unknown Fax <br /> APN Entail: i <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name RAY GARCIA/BERTHA GARCIA <br /> Title , r)�g <br /> Day Phone 209-P38-3986pti <br /> Night Phone //11 l(�t�!�b r <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026516 <br /> Mail Invoices to Facility Mail Invoices to: -Owner 1 Facility I Account <br /> Account Name GARCIA SEPTIC SERVICE (Circle One) <br /> Account Balance as of 5.11312009: $300.00 <br /> (Circle One) <br /> Transfer to ActiveRnadve <br /> Program/Elemenl and Description Record ID Employee ID and Name Status New Owner? Delete ! <br /> 4244-PUMPER TRUCK PRO522592 EE0004045-TED TASIOPOU LOS Inactive Y N A I D <br /> 4244-PUMPER TRUCK PRO522593 EE0004045-TED TASIOPOU LOS Inactive Y N A I D <br /> 4244-PUMPER TRUCK PRO526864 EE0004045-TED TASIOPOU LOS Active Y N A I D <br /> I <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,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 certifythat all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFER ED: *$20.00= Amount Paid Date ! / <br /> ' Water System to be TRANSFERED: *$372.00= Amount Paid Date I I 1 <br /> i <br /> Payment Type' Check Number Received b 1 <br /> REHS: Date 1 I Account out: Date 7 ? <br /> COMMENTS: I <br /> i <br /> f <br /> i <br /> l <br /> 11eh-envWnvisionVeports15021.rpt <br />