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Date un 2/7/2022 1:25:34PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by ` Page2 <br />Facility Information as of 2/7/2022 <br />Record Selection Criteria: Facility ID FA0000620 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID <br />OW0000500 <br />Owner Name <br />UNITED SITE SERVICES OF CA INC <br />Owner DBA <br />UNITED SITE SERVICES <br />OwnerAddress <br />201 ROSCOE RD <br />MODESTO, CA 95357 <br />Work/Business Phone <br />408-835-0867 <br />Alternative Phone <br />408-835-0867 <br />Mailing Address <br />-201 Re6H6-E)E—ftE�r <br />7 <br />Care of <br />SILVA, JOSE <br />FACILITY FILE INFORMATION APN <br />Facility ID / CERS ID FA0000620 <br />Facility Name UNITED SITE SERVICES <br />Location 201 ROSCOE RD <br />MODESTO, CA 953571828 <br />Phone 408-835-0867 <br />Mailing Address Z'0''rRGSGC))F= FSB <br />Care of SILVA, JOSE <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name SILVA, JOSE <br />Title <br />Day Phone 408-835-0867 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0000619 <br />Mail Invoices to Facility <br />Account Name UNITED SITE SERVICES <br />Email invoice to (up to 2 emails) <br />Email permit to (up to 2 emails) <br />Account Balance as of 2/7/2022: $0.00 <br />Program/Element and Description <br />4246 - PUMPER YARD <br />4255 - CHEMICAL TOILETS <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID <br />Mail Invoices to: <br />Record ID Employee ID and Name <br />PR0536470 EE0000039 -AARON GOODERHAM <br />PR0420092 EE0000039 -AARON GOODERHAM <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Status New Owner? Delete <br />Active,) Y N A I D <br />Active 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 with this facility <br />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 all applicable Ordinance Codes and/or Standards and State andlor <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: <br />COMMENTS: <br />Date <br />` $25.00 = Amount Paid Date <br />Amount Paid Date <br />Received b <br />Date / / Account out: Date a / / <br />Invoice #: <br />