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D;-a �1 28/2007 2:48:11PI SAN JC>AQUIN COUNTY ENVIRONMENTAL HE'-TH DEPARTMENTRRepot+it5D2f <br /> Facility Information as of 12128�d7 Paget <br /> Rion criteria: Fad ity iD FA0003350 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> Owner ID OW0000204 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 <br /> SAN JOSE, CA 95136 <br /> Care of UNITED SITE SERVICES OF CA INC <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0003350 <br /> Facility Name UNITED SITE SERVICES <br /> Location 360 N TENTH ST <br /> SACRAMENTO, CA 95814 <br /> Phone 916-444-2742 <br /> Mailing Address 3408 HILLCAP AVE <br /> SAN JOSE, CA 951361306 <br /> Care of MELLIFONT, KEVIN <br /> Location Code 01 -STOCKTON APN:15318054 <br /> SOS District 001 -GUTIERREZ, STEVE SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002927 NewAccount ID: : <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name UNITED SITE SERVICES (Circle One) <br /> Account Balance as of 1212812007: $0.00 <br /> T (Circle One) <br /> Transfer to <br /> AdiveMadve <br /> Pr ram/Bement and Description Record ID Employee New Owner? Delete <br /> Program/Bement P p oyes ID and Name Status <br /> 4740-WASTE TIRE SITE-EXEMPT PRO524551 EE0000060-JENNIFER FRASE Inactive 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 proded specific.PHSIEHD 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 ail applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws, <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date I / <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date I 1 <br /> Payment Type Check Number Received b)ri <br /> REHS: _l,4���., Date f 2 1 Z� 1 Q Account out: _ Date 1 1 <br /> COMMENTS: <br /> Ilphs-ehsqf-ntlappskenvisionsVeportsW021.rpt <br />