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Dete run 11/27/2007 8:23:36A SAN JF '?UIN COUNTY ENVIRONMENTAL HES--'H DEPARTMENT Report#5021 <br /> Run by %"01 Paget <br /> Facility Information as of 11I271�17 <br /> Record,Selection Criteria: Facility ID FA0003350 <br /> Make changes/corrections in RED ink or penclL <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <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 /> BOS District 001 - GUTIERREZ, STEVE SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002927 New Account ID <br /> Mail Invoices to Facility Mail Invoices to: Owner I Facility 1 Account <br /> Account Name UNITED SITE SERVICES (Circle One) <br /> Account Balance as of 11/27/2007: $4,254.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgremlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4740-WASTE TIRE SITE-EXEMPT PR0524551 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 project specific,PHS/EHD hourly charges associated Wth this <br /> facility or activity will be billed to the party identified as a OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and for Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: t-�� Date .1 <br /> Program Records to be TRANSFERED:Y '$20.00= Amount Paid l y/ Date IcMP7 <br /> Water System to be TPAANSFqEW "$372.00= Amount Paid Date IVZ21 <br /> Payment Type Check Number Received by <br /> REHS: 32 1 Date !( 102 Account out: Date�j I 1 1-7 I_d7 <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> NOV 2 7 2007 <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL <br /> q 6\0 0 tJEALTH DEPARTMENT <br /> llphs-ehsql-ntlappslenvisionslreports15021.rpt �� <br />