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;# 3/4/2009 8:36:50AM S f% IN COUNTY ENVIRONMENTAL,HEIH DEPARTMENT Repat#502t <br /> Pagel <br /> Facility Information as of 3!412009 <br /> Record Selection Criteria: Facility ID ` FA0000251 ' <br /> Make changeslcorrections in RED ink or pencil. <br /> �—� INFORMATION CHANGE(date) <br /> l <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION 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 /> Work/Business Phone 209-464-3009 <br /> Mailing Address 3408 HILLCAP AVE j <br /> SAN JOSE, CA 95136 1 <br /> Care of UNITED SITE SERVICES OF CA INC <br /> FACILITY FILE INFORMATION i <br /> Facility ID FA0000251 <br /> Facility Name PORTOSAN j <br /> Location 4550 E MARIPOSA RD <br /> STOCKTON, CA 95215 � <br /> Phone 800-262-2995 <br /> i <br /> Mailing Address 3408 HILLCAP AVE <br /> SAN JOSE, CA 951361306 <br /> Care of UNITED SITE SERVICES ' <br /> Location Code 99-UNINCORPORATED f All:Phone <br /> BOS District 002 - RUHSTALLER, LARRY ' Fax <br /> APN 17908258 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name KAREN PALACIO <br /> Title STEVE COOK \ ty` �n <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 J Facility / Account <br /> Account Name PORTOSAN 1 w J (Circle One) <br /> Account Balance as of 31412009: $0.00Y°w`T <br /> oma./ <br /> (Circle One) l <br /> Program/Element and Description Transfer to Acdvelbactve <br /> *� Record Ib Employee ID and N e Status New Owner? Delete <br /> 4244-PUMP PR0420 EE0004045-TED TASIOPOULOS Y N A 1 0 <br /> EE0005944-MICHAEL ESCOTTO Y N A I D . <br /> �._ EE0004045-TED TASIOPOULOS Active Y N A I D <br /> BILLING and COMPLIANCE ACKNO LEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSlEHD hourly charges associated with this <br /> facility or activity will be billed to the p identified aslbaA is form. I also certify that all operations will be performed in accordance with all applicable Ordinate Codes andlor Standards and <br /> State <br /> an Federal Laws. �r <br /> mar A <br /> APPLICANT'S SIGNATURE: Date <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 Type Check Number Received by <br /> REHS: \ Date 1 1 Account out: Date 1 I C R, 9�Ile— <br /> COMMENTS: <br /> WPB cel t.rt /1't�c /1,rC /vl R 5 T`/` -1)0002-5 1 <br /> 11eh-envlenvisionVeports15021.rpt <br />