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Date run 11/30/2010 9:18:24AI <br /> Run by SAN JOi IN COUNTY ENVIRONMENTAL HEAI,JDEPARTMENT Report 05021 <br /> i <br /> Facility Information as of 11/30/2010 Paget <br /> Record Selection Criteria: Facility ID FA0015392 <br /> i <br /> # Make changesicorrections in RED ink. <br /> .I <br /> I INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> SSN/Fed Tax ID F <br /> Owner ID OW0012358 New Owner ID <br /> Owner Name WINDMILL SEPTIC SERVICE " <br /> Owner DBA ; <br /> Owner Address PO BOX 96 ; <br /> 1 RIPON, CA 95366 <br /> j Horne Phone 209-823-1315 <br /> WorkBusiness Phone Not Specified I <br /> Mailing Address PO BOX 96 1 <br /> RIPON, CA 95366 <br /> Care of WINDMILL SEPTIC SERVICE <br /> FACILITY FILE INFORMATION <br /> 4 Facility ID FA0015392 k <br /> Facility Name WINDMILL SEPTIC SERVICE <br /> Location 20504 S HWY 99 FRONTAGE RD <br /> 4 RIPON, CA 95366 <br /> Phone 209-823-1315 <br /> Mailing Address 20504 S HWY 99 FRONTAGE RD <br /> RIPON, CA 95366 <br /> Care of <br /> Location Code 05- RIPON AR Phone <br /> Bos District 005 - ORNELLAS, LEROY Fax <br /> APN 22806017 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name RICK VAN UNEN <br /> Title <br /> - S <br /> Day Phone 209-823-1315 _- <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026517 New Account ID: : w <br />{ Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name WINDMILL SEPTIC SERVICE (CirdeOne) <br /> i Account Balance as of 1113012010: $1,042,00 <br /> - (Circle One) <br /> Transfer to Activelinactve <br /> Program/Bement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4244-PUMPER TRUCK PR0622594 EE0004045-TED TASIOPOULOS Active Y N A I D <br /> 4244-PUMPER TRUCK PRO526150 EE0004045-TED TASIOPOULOS Active Y , N A t D <br /> 4244-PUMPER TRUCK PRO526151 EE0004045-TED TASIOPOULOS Active Y N A I D <br /> 4244-PUMPER TRUCK PR0527381 EE0004045•TED TASIOPOULOS Active Y N A 1 D <br />+t 4246-PUMPER YARD PRO522595 EE0004045-TED TASIOPOULOS Active Y N A I D <br /> i <br /> 4255-CHEMICAL TOILETS PRO526152 EE0004045-TED TASIOPOULOS Active - Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0527075 EE0000060-JENNIFER FRASE 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,PHS/EHD hourly charges associated with this <br /> facility or activltywlll 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 f=ederal Laws. <br />'I <br /> APPLICANTS SIGNATURE. Date 1 I <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date 1 ! _ <br /> Water System to be TRANSFERED: Amount Paid Date / ! <br /> Payment Type Check Number Received by <br /> REHS: Date ! 1 Account out: Date <br /> COMMENTS: - <br /> �\eh-enY\efIVIS1071\repOftS\5p21.fpt I <br /> f <br />