BILLING - Laserfiche WebLink

Home Browse Search

Date run 11/18/2016 8:45:45A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 11/18/2016 Record Selection Criteria: Facility ID FA0015004 Account ID AR0025640 New Account ID: Mail Invoices to Facility Mail Invoices to: Owner / Account Name Pacific Gas and Electric Comapny Account Balance as of 11/18/2016: $0.00 i C�� Program/Element and Description Record ID Employee ID and Name r Status Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve New Owner? Delete 1920 - HMBP-Common Materials PR0522032 EE0009817 - ROBERT LOPEZ Inactive Y N l� I D 2220 - SM HW GEN <5 TONS/YR PR0539034 EE0001421 - STACY RIVERA Inactive Y N I D 4740 - WASTE TIRE SITE - EXEMPT PR0535043 EE0009000 - HARPRIT MATTU Inactive Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARGI PR0531568 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 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 Check Number Received by (( / / // /Y- EHD Staff: Z— Date �/�' / Account out: Date COMMENTS: 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 OW0012001 New Owner ID : Owner Name / !V� L / l Y c7..S � 1'z_ / � 4�l 1� � C_ `, i1 Owner DBA _ OwnerAddress 810 GILMORE AVE Qt"G' 8t 1:9*0 1 STOCKTO, CA 95203 Home Phone Not Specified Work/Business Phon Z0 `? _ 1.7 — 13J' 7 Mailing Address 1 Z Cab Q Care of FACILITY FILE INFORMATION Facility ID / CERS ID FA0015004 10184849 Facility Name Pacific Gas and Electric Comapny Location 810 GILMORE AVE STOCKTON, CA 95203 Phone c Mailing Address 810 GILMORE AVE - Rough & Ready Isl. STOCKTON, CA 95203 Care of Bepa444Rtrhst&4w17 Location Code Alt Phon BOS District 003 - BESTOLARIDES, STEVE Fax APN 16203007 EMail: EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0025640 New Account ID: Mail Invoices to Facility Mail Invoices to: Owner / Account Name Pacific Gas and Electric Comapny Account Balance as of 11/18/2016: $0.00 i C�� Program/Element and Description Record ID Employee ID and Name r Status Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve New Owner? Delete 1920 - HMBP-Common Materials PR0522032 EE0009817 - ROBERT LOPEZ Inactive Y N l� I D 2220 - SM HW GEN <5 TONS/YR PR0539034 EE0001421 - STACY RIVERA Inactive Y N I D 4740 - WASTE TIRE SITE - EXEMPT PR0535043 EE0009000 - HARPRIT MATTU Inactive Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARGI PR0531568 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 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 Check Number Received by (( / / // /Y- EHD Staff: Z— Date �/�' / Account out: Date COMMENTS: Invoice #: