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FD run 1/1012013 1:58:44PC SAN J(TIN COUNTY ENVIRONMENTAL HEA�1I DEPARTMENT <br /> oy Report rl'S0I7 <br /> Facility Information as of 1/10/20'3 Pagel <br /> rtl Selection Criteria f=acility ID FA0015495 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner lD OW0012448 New Owner ID <br /> Owner Name SCOTT DEBROUWER <br /> Owner DBA STOUT ROOFING OF CALIFORNIA IN <br /> Owner Address 3480 CARPENTER RID z c✓i y 6358 <br /> STOCKTON, CA 95215 you �ri�G7syf �j CA 9iL�9 <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 /> BOS District Fax <br /> APN 17916040 Entail: <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 lnvoicesto Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name SCOTT DEBROUWER (cmleOne) <br /> Account Balance as of 1/10/2013: $0.00 <br /> (Circle One) <br /> PropraMElemeM lioTransfer to Activefnachie <br /> end Oesuipn Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0522724 EE0002474-MICHAEL PARISSI Active Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0532918 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same.acknowledge that all site,andor project specific,PMS/EHD hourly charges associated with instal <br /> or activity will be billed to Ne party ideal as the OWNER on this form Ialso certify that all operations will be Performed in accordance with all applicable Ordinance Codes andor Standards and State andbr <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date / I <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type �—�—Check Number Received by <br /> OMME <br /> CNTS' 7 Date_/ / Account out: L - Date /�1 C <br /> COMME <br /> 7/��3 <br />