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Date run 10/22/2018 2:51:23F SAN JOAQUIN COUNTY ENARONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/22/2018 <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 Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OVV0011374 New Owner ID <br /> Owner Name HEATH, DOUGLAS/HADL, ELIZABETH <br /> Owner DBA NU SHAKE ROOFING <br /> Owner Address 708 INDUSTRIAL PARK DR C,D,E <br /> MANTECA, CA 95336 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-599-5993 <br /> Mailing Address 319 S PARALLEL AVE <br /> RIPON, CA 95366-2910 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0014323 10184599 <br /> Facility Name NU SHAKE ROOFING _ <br /> Location 708 INDUSTRIAL PARK DR STE C,D,E f I V-7 <br /> MANTECA, CA 95336 <br /> Phone 209-239-8616 <br /> Mailing Address 319 S PARALLEL AVE <br /> RIPON, CA 95366-2910 C77 <br /> Care of '�J' ' - � <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 Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name NU SHAKE ROOFING (Circle One) <br /> Account Balance as of 10/22/2018: $641.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0521244 EE0000009-NICHOLAS LOEHRER Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0522689 EE0009821 -KASHIF ALI Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0519150 EE0000000-HAZ MAT SJC OES InactivE Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533490 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 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 andtor <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 by I a <br /> EHD Staff: Date / 1 Account out: Date <br /> COMMENTS: RD-tri 12�7��� T���Z i , f �p.�yq Cm��� <br /> � r �,(Jlj� vN'(N J Invoic # ty Q�n�6 <br /> p60)faynL gu(7ine%' 4a.1v ynoVri to 312 5 FCLK4 Uet XVC a ✓on. <br />