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s Date tin <br /> Run by 4!712008 10:21:58AM SAN JOA zOIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#W21 Facility Information as of 4/7/2008 Page'{ <br /> Record Selection Criteria: Facility ID FAGO12769 <br /> Make changes/corrections;in RED Ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> k OWNER FILE INFORMATION <br /> r <br /> Owner ID OW 0009948 New Owner ID <br /> Owner Name GONZALEZ, SALVADOR <br /> Owner DBA SALVADOR GONZALEZ LABOR CONT <br /> Owner Address 217 FOURTH ST <br /> GALT, CA 95632 <br /> Home Phone 209-745-2223 <br /> Work/Business Phone Not Specified <br /> Mailing Address 217 FOURTH ST <br /> GALT, CA 95632 <br /> Care of GONZALEZ, SALVADOR <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012769 <br /> Facility Name SALVADOR GONZALEZ LABOR CONTRAC- <br /> Location 10065 KOST RD <br /> GALT, CA 95632 <br /> Phone 209-745-2223 <br /> Mailing Address 217 FOURTH ST <br /> GALT, CA 95632 <br /> Care of r <br /> Location Code 99- UNINCORPORATED AREA APN: <br /> BOS District 004-VOGEL, KEN SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0021369 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility ! Account <br /> Account Name SALVADOR GONZALEZ LABOR CONTRACTOR (Circle One) <br /> Account Balance as of 41712008: $0.00 <br /> Transfer to (Circle One) <br /> Active/Inactve <br /> Program/9ement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4244-PUMPER TRUCK — lLkk.cb PRO516744 EE0005366-LISA MEDINA Inactive Y N I D <br /> 4255-CHEMICAL TOILETS + 'kra • W PRO516745 EE0005366-LISA MEDINA Inactive Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned ownerAperator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party ides as the on this 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 <br /> Program Records to be TRANSFE '$20.00= Amount Paid Date 1 ! <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date ! / <br /> Payment T Check Number Received by <br /> REHS: Datl—,k efl Account out: Date ! / <br /> COMMENTS: <br /> �1 <br /> llphs-ehsgl-rrtlappslenvisionslreports15021.rpt <br />