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Date run 12/29/2015 10:22:59/ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/29/2015 <br /> Record Selection Criteria'. Facility ID FA0000253 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 SSN/Fed Tax ID <br /> Owner ID OW0000206 New OwnerlD <br /> Owner Name WILLIAMS, DARREN T <br /> Owner DBA WILLIAMS SANITARY SERVICE <br /> Owner Address 61 HANSON LN <br /> BRENTWOOD, CA 94513 <br /> Home Phone 925-634-4855 <br /> Work/Business Phone Not Specified <br /> Mailing Address 61 HANSON LN <br /> BRENTWOOD, CA 94513 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0000253 <br /> Facility Name WILLIAMS SANITARY SERVICE <br /> Location 61 HANSEN LN <br /> BRENTWOOD, CA 94513 <br /> Phone 925-634-4855 <br /> Mailing Address PO BOX 20 <br /> BRENTWOOD, CA 94513 <br /> Care of DARREN WILLIAMS <br /> Location Code 98 - OUT OF COUNTY Alt Phone <br /> BOS District Fax <br /> APN EMail <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name DARREN WILLIAMS <br /> Title <br /> Day Phone 925-634-4855 <br /> Night Phone 925-584-4548 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000252 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name WILLIAMS SANITARY SERVICE (Circle One) <br /> Account Balance as of 12/29/2015: $198.00 <br /> (Circle One) <br /> Transferto Active/Inacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4244-PUMPER TRUCK PR0420121 EE0004045-TED TASIOPOULOS Inactivr Y N A I D <br /> 4244-PUMPER TRUCK PRO527254 EE0004045-TED TASIOPOULOS Active Y N A D <br /> 4246-PUMPER YARD PR0536488 EE0004045-TED TASIOPOULOS Active,l Y N A D <br /> 4255-CHEMICAL TOILETS PRO527255 EE0004045-TED TASIOPOULOS Active Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anctor project specific,PHSIEHD hourly charges associated with thistacility <br /> or activity will be billed to the party identified as the OWNER on this form, l also codify that all operations will be performed in accordance with all applicable Ordinance Codas sector Standards and State ands <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <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 /> EHD Staff: Date / / Account out: Date i� / 301 /5— <br /> COMMENTS: <br /> 30 / /5— <br /> COMMENTS: <br /> �� « stid� )v yi1a � Invoice#: <br />