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1 <br /> ��+•''` y � - 1? � 1 <br /> -31412009 8:36:50AM S IN COUNTY ENVIRONMENTAL HEA -I DEPARTMENT Report 1Y5021 <br /> Run by Pagel s <br /> Facility Information as of 3/4/2009 <br /> Record Selection Criteria: Facility ID FA0000251 <br /> Make changesicorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) j <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN I Fed Tax ID <br /> Owner ID OW0000204 New Owner ID <br /> Owner Name UNITED SITE SERVICES OF CA INC <br /> Owner DBA <br /> Owner Address 3408 HILI_CAP AVE <br /> SAN JOSE, CA 951361306 ' <br /> Home Phone 916-444-2742 <br /> Work/Business 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 4580 E MARIPOSA RD <br /> STOCKTON, CA 95215 <br /> f. Phone 800-262-2995 <br /> Mailing Address 3408 HILLCAP AVE <br /> SAN JOSE, CA 951361306 J <br /> Care of UNITED SITE SERVICES <br /> Location Code 99- UNINCORPORATED E Alt Phone 1 <br /> BOS District 002- RUHSTALLER, LARRY Fax <br /> APN 17908258 Entail: <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 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name pORTOSAN v �� � �P �.. (Circle One) <br /> Account Balance as of 31412009: $0A0 �� +�jT 1 <br /> �� -/l�j aYC/' � �a��3'�� c*- (Cirde One) ' <br /> i��{_ Transfer to Activdlnadve <br /> Program/Bement and Description (A Record IDrEmploye�l =and e Status New Owner? Delete <br /> 4244-PUMP PRO420 EE0004045-TED TASIOPOULOS Y N A I D <br /> _-_U R EE0005944-MICHAEL ESCOTTO Y N A 1 D <br /> 66—G HEpyral Tn - EE0004045-TED TASIOPOULOS Active Y N A I D I <br /> BILLING and COMPLIANCE ACKNO LEDGEMENT: I,the undersigned owner,operator or agent of sane,acknowledge that all site,and/or project specific.PHSlEHO hourly charges associated with this <br /> facility or activity will be billed to the p identified a the OWN is form. I also certify that all operations will be performed in axordalce with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date I ! <br /> Water System to be TRANSFERED: "$372.00= Amount Paid Date 1 1 <br /> Payment Type Check Number Received by <br /> RENS: Date 1 I Account out: Date 1 I <br /> COMMENTS: , <br /> y✓t� t-.l <br /> r �6 00025, I <br /> . tteh-en,nenvisionlreports15021.rpt <br /> a _ - <br />