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Date run 12/19/2022 9:34:53A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/19/2022 <br /> Record Selection Criteria: Facility ID FA0000760 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0000603 New Owner ID <br /> Owner Name HUNT, SANDRA& GROVER LEROY JR <br /> Owner DBA C&C CHEMICAL TOILET RENTAL#843 <br /> OwnerAddress PO BOX 1523 <br /> RIVERBANK, CA 95367 <br /> Work/Business Phone Not Specified <br /> Alternative Phone 209-869-4395 <br /> Mailing Address PO BOX 1523 <br /> RIVERBANK, CA 95367 <br /> Care of C&C CHEMICAL TOILET RENTAL <br /> FACILITY FILE INFORMATION APN <br /> Facility ID/CERS ID FA0000760 <br /> Facility Name C&C CHEMICAL TOILET RENTAL <br /> Location 3111 STANISLAUS ST#13 <br /> RIVERBANK, CA 95367 <br /> Phone 209-869-4395 <br /> Mailing Address PO BOX 1523 <br /> RIVERBANK, CA 95367 <br /> Care of SANDRA HUNT& GROVER LEROY JR <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name C&C CHEMICAL TOILET RENTAL <br /> Title <br /> Day Phone -2A@ 17'i <br /> Night Phone Qg 869 489&_ I L'C <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000759 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility 1 Account <br /> Account Name C&C CHEMICAL TOILET RENTAL (Circle One) <br /> Email invoice to(up to 2 emails) m_�v 'r qua 6 6`d M c0. C GM r/ <br /> Email permit to(up to 2 emails) <br /> Account Balance as of 12/19/2022: $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 PR0420005 EE0004045-TED TASIOPOULOS Inactive Y N A I D <br /> 4244-PUMPER TRUCK PR0526637 EE0004045-TED TASIOPOULOS Inactive Y N A I D <br /> 4244-PUMPER TRUCK PRO539737 EE0000039-AARON GOODERHAM Active Y N A I D <br /> 4246-PUMPER YARD PR0536474 EE0000039-AARON GOODERHAM Active,I Y N A I D <br /> 4255-CHEMICAL TOILETS PR0420093 EE0000039-AARON GOODERHAM 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 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 performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <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 <br /> EHD Staff: A Date 12— 22 Account out: <br /> COMMENTS: <br /> Invoice#: <br />