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I <br /> { <br /> Date�n 6/22/2010 12:25:51PI1 SAN JCX�UIN COUNTY ENVIRONMENTAL HEA��i DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/22/2010 <br /> Record Selection Criteria: Facility ID FA0000131 <br /> l Make changeslcorrections in RED ink. <br /> �t INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION v "`� � � SSN IFed Tail ID <br /> Owner ID OW0000112 New Owner ID <br /> Owner Name S & C SEPTIC SERVICE INC E { <br /> Owner DBA G &C SEPTIC TANK SERVICE <br /> r. Owner Address 12851 STOCKTON BLVD <br /> GALT, CA 95632 <br /> Home Phone 2009-368-3933 <br /> Work/Business Phone Not Specified <br /> Mailing Address :PO BOX 127 <br /> GALT, CA 95632 <br /> Care of SHON OR CONNIE STEELE <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000131 <br /> Facility Name G &C SEPTIC TANK TRUCK <br /> Location 12851 STOCKTON BLVD <br /> GALT, CA 95632 <br /> Phone 209-368-3933 1 <br /> I <br /> Mailing Address PO BOX 127 <br /> GALT, CA 956320127 <br /> Care of SHON OR CONNIE STEELE <br /> Location Code 9$- OUT OF COUNTY Aft Phone <br /> BOS Distract Fax <br /> APN Email: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION AA0 <br /> Contact Name STEELE, RICK - <br /> Title TRUCK#1 <br /> Day Phone 209-368-3933 <br /> Night Phone 2D9-368-3933 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000130 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner I Facility / Account <br /> Account Name G & C SEPTIC TANK TRUCK (Circle One) <br /> Account Balance as of 6/22/2010: $0.00 <br /> � r (Circle One) <br /> Transfer to Activethadve <br /> Progfam/Element and Description Record ID Employee ID and Name stems New Owner? Delete <br /> 4244-PUMPER TRUCK PR0420107 EE0005366-LISA MEDINA Active Y N A I D <br /> 4244-PUMPER TRUCK �`� PR0420108 EE0005366-LISA MEDINA Active Y N A I D <br /> 4244-PUMPER TRUCK -� PR0420130 EE0005366-LISA MEDINA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent <br /> m <br /> of sae,acdmowledge that all site,and/or project specific,PHSIEHD hourly charges associated with this <br /> facility or activity will be billed to the party idenfified as the OWNER on this form. l also cerlify that all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <br /> Slate andler Federal Laws. <br /> APPLICANT'S SIGNA RE: <br /> Program Records to b ANSFER D: '$20.00= Amount.Paid Date 1 I <br /> W S to NSFERED: "$372:00= Amount Paid Date I ! <br /> aymentTp C�- Dzrte � / <br /> Rec -400EHS: �, �O�Ac�ount out: Date 1 1 <br /> C NTs: <br /> .lenvisionlreport515021.1pt <br />