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Dnte run 12/8/2022 9:27:48An ; SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 42/8/2022 <br /> Record Selection Criteria: Facility ID FA0000620 ` <br /> Make changes/corrections In RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION: Number of facilities for this owner: 1 SSN/Fed Tax ID _ <br /> Owner ID OW0000500 New Owner ID <br /> Owner Name UNITED SITE SERVICES OF CA INC <br /> Owner DBA UNITED SITE SERVICES _ <br /> Owner Address 201 ROSCOE RD _ <br /> MODESTO, CA 95357 _. <br /> Work/Business Phone 408-835-0867 <br /> Alternative Phone 408-835-0867 <br /> Mailing Address 118 FLANDERS RD _ <br /> VVESTBOROUGH, MA 01581 <br /> Care of Si LVA, JOSE <br /> FACILITY FILE INFORMATION APN <br /> Facility ID/CERS ID FA0000620 _. <br /> Facility Name UNITED SITE SERVICES <br /> Location 2_01 ROSCOE RD <br /> MODESTO, CA 953571828 _ <br /> Phone 4Q8-835-0867 <br /> Mailing Address 118 FLANDERS RD <br /> WESTBOROUGH, MA 01581 <br /> Care of SILVA, JOSE _ <br /> EMERGENCY NOTIFICATIONCONTACT INFORMATION <br /> Contact Name 51LVA, JOSE _ <br /> Title _ <br /> Day Phone 408-835-0867 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000619 New Account ID: <br /> Mail Invoices to F=cillty Mail Invoices to: Owner ! Facility 1 Account <br /> Account Name UNITED SITE SERVICES (Circle One) <br /> Email invoice to(up to 2 emails) <br /> Email permit to(up to 2 emails) <br /> Account Balance as of 12/8/2022: $5,712.00 <br /> (Circle Ona) <br /> Transfer to Activetlnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4246-PUMPER YARD PRO536470 EE0000039-AARON GOODERHAM Active,! Y N A 1 D <br /> 4255-CHEMICAL TOILETS PR0420092 EE0000039-AARON GOODERHAM Active Y N A I D <br /> BILLING and COMPLWNCE ACKNOWLEDGEMENT: (.the undersign owner,operator or agent of same,acknowledge that all site,andlor project spacfftc,PHSIEHD hourly charges associated with this lacirtty <br /> or activity will be billed to the party identified a0he OWNS Iso certify that aft operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State anWor <br /> Federal Lays. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be T ANSF $25.00= Amount Paid Date i <br /> Water System to be TRAN E D Amount Paid Date i ! <br /> Payment Type a umber Received b _ <br /> EHD Staff: &GM Date�Z /_ / 71072-1 Account out: <br /> COMMENTS: <br /> Invoice#: <br />