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Date run 6/26/2017 9:00:45AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 6/26/2017 <br />Record Selection Criteria: Facility ID FA0010987 <br />OWNER FILE INFORMATION Number of facilities for this owner : 1 <br />Owner ID OW0008987 Case Number: H09106 <br />Owner Name R <br />Owner DBA _AC4F.)C –6-Uf31fL O <br />OwnerAddress ^429 <br />-NORTf "=HGHl�, CA -95660' <br />Home Phone Not Specified <br />Work/Business Phone -91i5—_444 -_93W4 -- <br />Mailing Address <br />5660 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0010987 10119784 <br />Facility Name-AN-ERSOnzFR.U�S­S--- <br />Location 2050 E LOUISE AVE <br />LATHROP, CA 95330 <br />Phone 20q-_858_&58+ <br />Mailing Address <br />ND 95666 - <br />Care of PA <br />Location Code 07 - LATHROP <br />Bos District 003 - BESTOLARIDES, STEVE <br />APN 19816002 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) (j 2 712017 <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />Ne Apwner ID <br />e Meat <br />rZ5 <br />2_ <br />r 9009rt <br />Fax <br />EMail : <br />Contact Name <br />Title <br />Day Phone <br />— <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0017987 <br />New Account ID: <br />Mail Invoices to Facility <br />Mail Invoices to: <br />Owner / <br />Facility / Account <br />Account Name ANDERSON TRUSS <br />(Circle One) <br />Account Balance as of 6/26/2017: $0.00 <br />(Circle One) <br />Transfer to Active/lnactve <br />Program/Element and Description Record ID <br />Employee ID and Name <br />Status <br />New Owner? Delete <br />1921 - HMBP-Regular-Primary Location PR0520589 <br />EE0000009 - NICHOLAS LOEHRER <br />Inactive <br />Y N A I D <br />2220 - SM HW GEN <5 TONS/YR PR0514483 <br />EE9999997 - TWO VACANT2 <br />Inactive <br />Y N I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513275 <br />EE9999997 - TWO VACANT2 <br />Inactive <br />Y N I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0510987 <br />EE0000000 - HAZ MAT SJC OES <br />InactivE <br />Y N A I D <br />2832 - AST FAC 10 K- </=100 K GAL CUMULATIVE PR0516363 <br />EE0002646 - THUY TRAN <br />InactivE <br />Y N A I D <br />4740 - WASTE TIRE SITE - EXEMPT PR0524248 <br />EE0007379 -AMANDA BOERTIEN <br />Inactive <br />Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGI PR0534450 <br />InactivE <br />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 andfor <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: ' $25.00 = <br />Amount Paid Date <br />Water System to be TRANSFERED: <br />Amount Paid Date <br />Payment Type Check Number <br />Received b <br />EHD Staff: /V),-- l ch Date E /-2--7 Account out: <br />Date �/)7 <br />COMMENTS: / l � b vate /9)—/ <br />9)—f 1—h <br />% l c ke rr1 t a1 C � Invoice #: I �'� <br />