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Date run 11/16/2006 10:29:58/ SAN JOIN COUNTY ENVIRONMENTAL HEA DEPARTMENT <br /> Report#5021 <br /> Run by r Pagel <br /> Facility Information as of 11/16/2006 <br /> Record Selection Criteria: Facility ID FA0000629 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0000504 New Owner ID <br /> Owner Name USA WASTE SERVICES, INC <br /> Owner DBA MODESTO DISPOSAL SERVICE <br /> Owner Address 8761 YOUNGER CREEK DR <br /> SACRAMENTO, CA 95828 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-538-2210 <br /> Mailing Address 2769 W HATCH RD <br /> SACRAMENTO, CA 95828 <br /> Care of USA WASTE SERVICES, INC <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000629 <br /> Facility Name CAL STATE RENTALS INC <br /> Location 2769 W HATCH RD <br /> MODESTO, CA 95358 <br /> Phone 209-538-8919 <br /> Mailing Address 2769 W HATCH RD <br /> MODESTO, CA 95358 <br /> Care of THOM CLARK <br /> Location Code 98-OUT OF COUNTY APN: <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000628 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name CAL STATE RENTALS INC (Circle One) <br /> Account Balance as of 11/16/2006: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4244-PUMPER TRUCK PR0420138 EE0004045-TED TASIOPOULOS Active Y N A Ul D <br /> 4244-PUMPER TRUCK PR0420139 EE0009374-LARRY GODINHO Inactive Y N A I D <br /> 4244-PUMPER TRUCK PRO506470 EE0009374-LARRY GODINHO Inactive Y N A I D <br /> 4255-CHEMICAL TOILETS PR0420137 EE0004046-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,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the parry Identiped as the OWNER on this form. I also derby that all operations will be performed In accordance with all applicable Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Dale <br /> Program Records to be TRANSFEREO: "$20.00= Amount Paid Date /_/ <br /> Water System to be TRANSFERED: _*$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: y Date / /_ Account out: Date / 7 L <br /> COMMENTS: <br /> f� � UGIolw.fe� (,.�1yh vlmr AQ�-. <br /> \\phs-ehsq I-nt\apps\envisions\reports\5021.rpt <br />