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Date run 715!2013 4:55:55PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Run by Report#5021 <br /> Facility Information as of 7/5/2013 Pagel <br /> Record Selection Critena: Facility ID FA0000640 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> FILE CUP "'sOWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> SSN!Fed Tax ID O'D <br /> Owner ID OW0000510 New Owner ID <br /> Owner Nar l VLIET, HUGO <br /> Own DBA L <br /> Owner Address 6613 WOODLAND AVE <br /> MODESTO, CA 953588502 <br /> Home Phone 209-577-1479 <br /> Work/Business Phone 209-577-4410 <br /> Mailing Address 6613 WOODLAND AVE <br /> MODESTO,CA 953588502 <br /> Care of " <br /> FACILITY FILE INFORMATION <br /> Facility ID!CERS ID FA0000640 I <br /> Facility Name A-1 SEPTIC SERVICE <br /> Location 6613 WOODLAND AVE I <br /> MODESTO, CA 953588502 <br /> Phone 209-577-1479 <br /> Mailing Address 6613 WOODLAND AVE <br /> MODESTO, CA 953588502 <br /> Care of HUGO VAN VLIET <br /> t Location Code 98 -OUT OF COUNTY Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name HUGO VAN VLIET <br /> Title <br />'- Day Phone 209-577-1479 <br /> Night Phone 209-577-4410 <br /> I <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000639 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility 1 Account <br /> Account Name A-1 SEPTIC SERVICE (Circle One) <br /> Account Balance as of 7/512013: $0.00 <br /> i (Circle One) <br /> Transferto Activellnactve <br /> ProgranVElement and Description Record 0 Employee ID and Name Status New Owner? Delete <br /> 4244-PUMPER TRUCK PR0420119 EE0004045-TED TASIOPOULOS Active Y N A I D <br /> 4246-PUMPER YARD PRO536472 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 project specific,PHSlEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form I also certify that all operations will be rtonned in accordance with all applicable Ordinance Codes andlor Standards and State and+or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: �� Y �'«� Date '7 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1. ! <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received Dy <br /> RENS: Date ! 1 Account out: Date '7 1 <br />` COMMENTS: <br /> { <br />