BILLING - Laserfiche WebLink

Home Browse Search

Date run 5/5/2017 3:27:44PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 5/5/2017 Record Selection Criteria: Facility ID FA0005692 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 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 andror Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: * $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received by EHD Staff: Date / / Account out: Date ! / D / COMMENTS: ll Invoice #: Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID Owner ID OW0004509 New Owner ID Owner Name ANTHONY VARNI Owner DBA SEVEN-UP BOTTLING CO OF STKN Owner Address 1109 W ANDERSON ST STOCKTON, CA 95206 Home Phone Not Specified Work/Business Phone 209-914-6959 Mailing Address 1109 W ANDERSON ST STOCKTON, CA 95206 Care of FACILITY FILE INFORMATION Facility ID / CERS ID FA0005692 10181915 Facility Name SEVEN-UP BOTTLING CO OF STOCKTON Location 1109 W ANDERSON ST STOCKTON, CA 95206 Phone 209-521-1777 x Mailing Address 1109 W. ANDERSON ST STOCKTON, CA 95206 AA Care of ANTHONY VARNI Location Code 01-STOCKTON Alt Phone BOS District 001 - VILLAPUDUA, CARLOS Fax APN EMail: EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0006361 New Account ID: Mail Invoices to Account Mail Invoices to: Owner / Facility ! Account Account Name ANTHONY VARNI (Circle One) Account Balance as of 5/5/2017: $0.00 (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? ,�Deelleette 1921 - HMBP-Reqular-Primary Location PR0520362 EE0009817 - ROBERT LOPEZ Active Y N A . I-- D C 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511888 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2381 - UST FACILITY (BEFORE 1/84) - obsolete PR0503128 EE0000418 - MICHAEL KITH Inactive Y N A I D 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509600 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0532708 Inactive Y N A I D 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 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 andror Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: * $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received by EHD Staff: Date / / Account out: Date ! / D / COMMENTS: ll Invoice #: