Laserfiche WebLink
Date mn _-2/20/2013 11:15:21AI SAN K IIPI COUNTY ENVIRONMENTAL HEATDEPARTMENT Reportk5021 <br /> Run by <br /> Facility Information as of 2/20/2013 Pagel <br /> Record selection Criteria: Facility ID FA0014323 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0011374 New Owner ID <br /> Owner Name HEATH, DOUGLAS/HADL, ELIZABETH <br /> Owner DBA NU SHAKE ROOFING <br /> Owner Address 708 INDUSTRIAL PARK DR STE C,D,E <br /> MANTECA, CA 95336 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-599-5993 <br /> Mailing Address 708 INDUSTRIAL PARK DR STE C D E AUe� <br /> MANTECA, CA 95336 Ma;i251.1,s-2,11c) <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014323 <br /> Facility Name NU SHAKE ROOFING <br /> Location 708 INDUSTRIAL PARK DR STE C,D,E <br /> MANTECA, CA 95336 <br /> Phone 209-239-8616 <br /> Mailing Address 708 INDUSTRIAL PARK DR STE C D E <br /> MANTECA, CA 95336 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 22119021 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0024338 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name HEATH, DOUGLASMADL, ELIZABETH (Circle one) <br /> Account Balance as of 2/20/2013: $348.00 <br /> (Circle One) <br /> Transfer to Active/Inache <br /> PrograndElement and Description Record ID Employee ID and Name Status New Omen Delete <br /> SHMBP-Common Materials PRO521244 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220- M HW GEN<5 TONSNR PRO522689 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> -UNIFIED PROGRAM FAC STATE SURCHAR(PRO519150 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCRPRO533490 Inactive 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 spec,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 andbr Standards and State anclor <br /> Federal Laws. <br /> APPLICANTS 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 Receivedy <br /> REHS: Date_/_/ Account out: Date_/_/ �� <br /> COMMENTS: <br />