BILLING - Laserfiche WebLink

Home Browse Search

Date run 3/7/2016 9:39:32AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 3/7/2016 Record Selection Criteria: Facility ID FA0012705 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0015220 Owner Name LUAN, JESSICA Owner DBA T4 Owner Address 584 W TRAMONTO DR Phone MOUNTAIN HOUSE, CA 95391 Home Phone 510-957-3078 Work/Business Phone 510-928-3152 Mailing Address 584 W TRAMONTO DR Location Code MOUNTAIN HOUSE, CA 95391 Care of LUAN, JESSICA FACILITY FILE INFORMATION Facility ID / CERS ID FA0012705 10184325 Facility Name T4 Location 1215 W MARCH LN STOCKTON, CA 95207 Phone 510-928-3152 Mailing Address 584 W TRAMONTO DR MOUNTAIN HOUSE, CA 95391 Care of LUAN, JESSICA Location Code 01 - STOCKTON Bos District 002 - MILLER, KATHERINE APN 10816010 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name LUAN, JESSICA Title Day Phone 510-928-3152 Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0021144 Mail Invoices to Facility Account Name T4 t� Account Balance as of 3/7/2016: $.00 Make changestcorrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) 1 SSN / Fed Tax ID New Owner ID : Alt Phone Fax _ EMail : Mail Invoices to: New Account ID: : Owner / Facility / Account (Circle One) (Circle One) LTransfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1624 - RESTAURANT/BAR 21-50 SEATS PR0516610 EE0006213 - VIDAL PEDRAZA Active Y N A I D 1921 - HMBP-Regular-Primary Location PR0530842 EE0000006 - HAZA SAEED Active Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARGE PR0532262 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 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 EHD Staff: �� Date/�/ '\k -,b Account out: Date COMMENTS: Invoice #: