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Date run w 12128!2007 10:53:37A SAN JC"UIN COUNTY ENVIRONMENTAL HE/ H DEPARTMENT <br /> Run by Report afS021 <br /> Facility Information as of 12/28/2 07 Pagel <br /> Record Selection Criteria: Fadlity ID FA0000153 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> Owner ID OW 0000130 New Owner ID <br /> Owner Name BIBB, LINDA <br /> Owner DBA CLARK SEPTIC SERVICE LLC <br /> Owner Address 852 CHARLES RD <br /> HUGHSON, CA 953226 <br /> Home Phone 209-537-6624 <br /> Work/Business Phone 209-537-6624 <br /> Mailing Address PO BOX 1475 <br /> HUGHSON, CA 953261475 <br /> Care of BIBB, LINDA <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000153 <br /> Facility Name CLARK SEPTIC SERVICE LLC <br /> Location 852 CHARLES RD <br /> HUGHSON, CA 95326 <br /> Phone 209-537-6624 <br /> Mailing Address PO BOX 1475 <br /> HUGHSON, CA 953261475 <br /> Care of BIBB, LINDA <br /> Location Code 98- OUT OF COUNTY APN: <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000152 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner ! Facility ! Account <br /> Account Name CLARK SEPTIC SERVICE LLC (CirdeOne) <br /> Account Balance as of 12/28/2007: $0.00 <br /> (Circle One) <br /> Transfer to p,ctivelinauve <br /> Pr ram/Element and Desai fion Record ID Employee New Owner? Delete <br /> 09 p p ogee[D end Name Status <br /> 4244-PUMPER TRUCK PR0420131 EE0004045-TED TASIOPOULOS Inactive Y N A I D <br /> 4244-PUMPER TRUCK PRO526614 EE0004045-TED TASIOPOULOS 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,PHSIEHD hourly charges assodated with this <br /> facility or activity will be billed to the party Identified as the OWNER on this form. I also Certify that elf operations will be performed in accordance with all applicable Ordlnaos Codes and/or Standards and <br /> State andlor Federal laws. <br /> APPLICANT'S SIGNATURE: Date I / <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date / ! <br /> Water System to be TRANSFERED: `$372.00= Amount Paid Date I I <br /> Payment Type Check Number Received.b,�,I <br /> REHS: Date 12-8 Accountout: Date <br /> COMMENTS: 1. <br /> r� D✓ 7C f �'OC`�" <br /> llphs-ehsgl-rnLappslenvisionslrePWSs 5021.rpt <br />