BILLING - Laserfiche WebLink

Home Browse Search

Date run 5/18/2015 4:03:17PN SAN , JUIN COUNTY ENVIRONMENTAL HF 'H DEPARTMENT Report #5021 Run by Pagel Facility Information as of 5/18/2015 Record Selection Criteria: Facility ID FA0003077 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0014511 Owner Name Harman Management Corporation Owner DBA 400 W ELEVENTH ST OwnerAddress 2846 VOLPEY WAY Phone UNION CITY, CA 94587 Home Phone 510-429-7925 Work/Business Phone 650-941-5681 Mailing Address 199 First Street, Suite 212 Location Code Los Altos, CA 94022 Care of ROGERS, STAN FACILITY FILE INFORMATION Facility ID/ CERS ID FA0003077 10181055 Facility Name KENTUCKY FRIED CHICKEN #224 Location 400 W ELEVENTH ST TRACY, CA 95376 Phone 209-835-3308 x Mailing Address 2846 Volpey Way 1921 - HMBP-Regular-Primary Location Union City, CA 94587 Care of Kern 224, Inc. Location Code 03 -TRACY BOS District 005 - ELLIOTT, BOB APN 23504011 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name KENTUCKY FRIED CHICKEN Title Day Phone 209-835-3500 Night Phone 209-835-3500 ACCOUNTS RECEIVABLE FILE INFORMATION Make changestcorrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) 1 SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail : Account ID AR0002640 Mail Invoices to Facility Mail Invoices to: Account Name KENTUCKY FRIED CHICKEN #224 Account Balance as of 5/18/2015: $65.00 New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1624 - RESTAURANT/BAR 21-50 SEATS PRO161421 EE0001420 - MELISSA NISSIM Active Y N A D 1921 - HMBP-Regular-Primary Location PR0527144 EE0002474 - MICHAEL PARISSI Active Y N A D ERSC - ELECTRONIC REPORTING STATE SURCHARGI PR0534142 Inactive Y N A 1 D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project speck, 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 andlor Standards and State and/or 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 y, Check Number Recei by EHD Staff: �9 ✓,1 Date 5—Account out: Date -�lL�l 5 COMMENTS: I # nvolce I �. tC U. S; -� l ��P `� V G��ry ?�P <c �c'G� �� /,57 f,,