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Date run 12/29/2008 9:46:46AI SAN JUIN COUNTY ENVIRONMENTAL HE/�;DEPARTMENT <br /> Run by Report*W21 <br /> Facility Information as of 12/29/2008 Pagel <br /> Record Selection Criteria: Facility ID FA0000251 <br /> Make changes/corrections in RED Ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID OW 0000204 New Owner ID <br /> Owner Name UNITED SITE SERVICES OF CA INC <br /> Owner DBA <br /> Owner Address 3408 HILLCAP AVE <br /> SAN JOSE, CA 951361306 <br /> Home Phone 916_444-2742 <br /> WorklBusiness Phone 209-464-3009 <br /> Mailing Address 3408 HILLCAP AVE <br /> SAN JOSE, CA 95136 <br /> Care of UNITED SITE SERVICES OF CA INC <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000251 <br /> Facility Name PORTOSAN <br /> Location 4550 E MARIPOSA RD <br /> STOCKTON, CA 95215 <br /> Phone 800-262-2995 <br /> Mailing Address 3408 HILLCAP AVE <br /> SAN JOSE, CA 951361306 <br /> Care of UNITED SITE SERVICES <br /> Location Code 99- UNINCORPORATED E Aft Phone <br /> BOS District 002- RUHSTALLER, LARRY Fax <br /> APN 17908258 EMall: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name KAREN PALACIO <br /> Title STEVE COOK <br /> Day Phone 916-631-0600 <br /> Night Phone 916-859-4790 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002834 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner I Facility 1 Account <br /> Account Name PORTOSAN (Circle One) <br /> Account Balance as of 12/29/2008: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Bement and DesrriPUW Record ID Employee ID and Name Status New Owner? Delete <br /> 4244-PUMPER TRUCK PR VO141 EE0004045-TED TASIOPOULOS Aoactive Y N A I D <br /> 4246-PUMPER YARDPR 23 EE0005944-MICHAEL ESCOTTO Y N A I D <br /> 4255-CHEMICAL TOILETS 333 . PR04 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 activity will be billed to the party identified as the OWNER an this form. 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 1 I <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: `$372.00= Amount Paid Date ! 1 <br /> Payment Type Check Number Received by <br /> RENS: Date 1 I Account out: Date 1 1 <br /> COMMENTS: <br /> Ileh-env\envision\Reports15021.rpt <br />