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Date run 1/6/2010 9:05:21AM SAN JOA- `N COUNTY ENVIRONMENTAL HEAL- IEPARTMENT <br /> Repoli#5021 <br /> fan by %- � <br /> Facility Information as of 1/6/2010 Pagel <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 SSN/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 PO BOX 1004 <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 <br /> Mailing Address PO BOX 1004 <br /> OAKDALE, CA 95361 <br /> Care of LARRY MASON <br /> Location Code 99- UNINCORPORATED A 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 1 Facility 1 Account <br /> Account Name MASON, LARRY (Circle One) <br /> Account Balance as of 11612010: $0.00 <br /> (Circle One) <br /> Transfer to Active/lnacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4244-PUMPER TRUCK PRO505614 EE0004045-TED TASIOPOULOS Active Y N A I D <br /> 4246-PUMPER YARD PRO508408 EE0004045-TED TASIOPOULOS Active Y N A 1 D <br /> 4255-CHEMICAL TOILETS PR0505613 EE0004045-TED TASIOPOULOS Active Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator 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 identified as the OWNER on this form. I also certify that 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 / 1 <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date ! I <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date / ! <br /> Payment Types Check Number Received by <br /> REHS: Date Ld Account out: Date_�I 1 0 C1I <br /> COMMENTS!' f1 <br /> -z- 8 <br /> 17 3) V Q Oj e 4!- <br /> 1&4, /FDXT116P, 1.��DS�go4! <br /> Ileh-envlenvis ionlreports15021.rpt <br />