Laserfiche WebLink
Date run 10/5/2016 2:28:30PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/512016 <br /> Record Selection Criteria: Facility ID FA0016240 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNED FILE INFORMATION Number of facilities for this owner: 1 SSN I Fed Tax ID <br /> Owner ID OW0013134 New Owner ID <br /> Owner Name <br /> Owner DBA <br /> OwnerAddress <br /> Home Phone <br /> Work/Business Phone 209-836-9463 <br /> Mailing Address 28644 S Tracy Blvd <br /> TRACY, CA 95378 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0016240 10185137 <br /> Facility Name <br /> Location 28644 S TRACY BLVD <br /> TRACY, CA 95378 <br /> Prone 209-836-9463 x <br /> Mailing Address 28644 S TRACY BLVD <br /> TRACY, CA 95378 <br /> Care of—%w4geveT1--s� <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN 25312033 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 AR0028403 NewAccount ID: <br /> Mail Invoices to Account Mail Invoices to: Owner I Facility I Account <br /> Account Name ABT Freight Lines (Circle one) <br /> Account Balance aS of 1015/2016: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramlElement and Description Record 0 Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO539045 EE0000010-PETER LOMBARDI Active Y N A I D <br /> 2227-GEN 5<25 TONS PERMIT PRO524189 EE0000019-HERLINDA MENCHACA Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO527074 EE0004486-ANGELICA SANDOVAL MARII Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO532074 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfer project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identied as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date / 1 <br /> Payment Type Chl Number Received b <br /> EHD Staff: Date f 0 I�1�_ Account out: <br /> COMMENTS: <br /> InV0ice#: <br />