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F <br /> e run 220@013 11:22:30A1 SAN JOe�,JIN COUNTY ENVIRONMENTAL HEAD DEPARTMENT by ' Report#5021 <br /> 1 Facility Information as of 2/20/2013 Paget <br /> R d S l ctCriteria Facility ID FA0015495 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0012448 New Owner ID <br /> Owner Name SCOTT DEBROUWER <br /> Owner DBA STOUT ROOFING OF CALIFORNIA IN <br /> Owner Address 3480 CARPENTER RD <br /> STOCKTON, CA 95215 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-461-7160 <br /> Mailing Address 3480 CARPENTER RD <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015495 <br /> Facility Name STOUT ROOFING OF CALIFORNIA INC <br /> Location 3480 CARPENTER RD <br /> STOCKTON, CA 95215 <br /> Phone 209-461-7160 x0 <br /> Mailing Address 3480 CARPENTER RD <br /> STOCKTON, CA 95215 <br /> Care of <br /> Location Code Alt Phone <br /> BOB District 001 -VILLAPUDUA Fax <br /> APN 17916040 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026737 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name SCOTT DEBROUWER (Circle One) <br /> Account Balance as of 2/20/2013: $350.00 <br /> (Circle One) <br /> PrograMElement and Description Record lD Em ee lD and Nama Status Transferto Active'Inactve <br /> poY New Owner' Delete <br /> 1921 -HMBP-Regular-Primary Location PR0522724 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPR0532918 Inactive Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned!owner,operator or agent of same,acknowledge Nat all site,andor Project specio,PHS/EHD hourly charges associated with this taallly <br /> or activity will be billed to Ne party identified as the OWNER on this form I also certify Nat all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State andor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: $25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid <br /> Payment Type --�--Check Number Rece d <br /> REHS: /1�� YGt.�.,� Date, Accountot D�atte / !� <br /> COMMENTS: <br /> 1�" <br />