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Date run 2/1/2010 3:23:27PM SAN JOA( N COUNT4ENV&ONMENTAL HEALT )EPARTMENT Report#5021 <br /> Run by I � <br /> Facility Information as of 2/1/2010 Paget <br /> Record Selection Criteria: Facility ID FA0006897 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION �r. � SSN 1 Fed Tax ID <br /> Owner ID OW0005662 New Owner ID <br /> Owner Name MASON, LARRY <br /> Owner DBA MASON ENTERPRISE <br /> Owner Address 1160 SKYVIEW DR <br /> OAKDALE, CA 953612624 <br /> Home Phone 209-838-3979 <br /> Work/Business Phone 209-838-3979 <br /> Mailing Address PAa-00 "04 <br /> OAKDALE, CA 95361 <br /> Care of LARRY MASON <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0006897 <br /> Facility Name MASON ENTERPRISE <br /> Location 17219 VICTORY RD <br /> OAKDALE, CA 95361 <br /> Phone 209-838-3979 5 <br /> Mailing Address ECLBOX-11NI4 wo a 5 1!-�,>r,� *e�„� •C , <br /> OAKDALE, CA 95361 <br /> Care of LARRY MASON <br /> Location Code 99 - UNINCORPORATED F Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name LARRY MASON <br /> Title <br /> Day Phone 209-838-3979 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0009709 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility I Account <br /> Account Name MASON, LARRY (Circle One) <br /> Account Balance as of 21112010: $0.00 <br /> (Circle One) <br /> Transfer to Activelinactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4244-PUMPER TRUCK PR0505614 EE0004045-TED TASIOPOULOS Inactive Y N A I D <br /> 4244-PUMPER TRUCK PRO531174 EE0004045-TED TASIOPOULOS Active Y N A 1 D <br /> 4246-PUMPER YARD PRO508408 EE0004045-TED TASIOPOULOS Active Y N A I D <br /> 4255-CHEMICAL TOILETS PRO505613 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,PHSIEHD hourly charges associated with this <br /> facility or activky 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 andlor Federal Laws. (} <br /> APPLICANT'S SIGNATURE: �`J et✓ df to cJI'A Date Z ! 1 I ku <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date I I <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date 1 I <br /> Payment Type Check!Number Received by <br /> by <br /> REHS: Date 1 I Account out: lard-Q— Date rL /—Z— 0 <br /> COMMENTS: <br /> Ileh-envlenvisionlreports15021.rpt <br />