Laserfiche WebLink
Date run 12/21/2017 11:22:03/ SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/21/2017 <br /> Record Selection Criteria: Facility ID FA0015564 <br /> Make changestcorrections 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 0'4,1110012513 New Owner ID ; <br /> Owner Name MEDINA, CARLOS & SANDRA <br /> Owner DBA HOLLAND ALIGNMENT& BRAKES <br /> OwnerAddress 3802 N WILCOX RD <br /> STOCKTON, CA 952152463 <br /> Home Phone 209-952-2218 <br /> Work/Business Phone 209-931-5807 <br /> Mailing Address 3802 N WILCOX RD <br /> STOCKTON, CA 95215-2463 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0015564 10184985 <br /> Facility Name HOLLAND ALIGNMENT& BRAKES <br /> Location 3$02 N WILCOX RD <br /> STOCKTON, CA 95215-2463 <br /> Phone 209-931-5807 x <br /> Mailing Address 3802 N WILCOX RD <br /> STOCKTON, CA 95215-2463 <br /> Care of CARLOS & SANDRA MEDINA <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District Fax <br /> APN 08722006 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 ARD026864 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name HOLLAND ALIGNMENT & BRAKES (Circle One) <br /> Account Balance as of 12/2112017: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO535250 EE0008709-JAMIE LIMA Active Y N A I D <br /> 2220-SM HW GEN <5 TONSIYR PR0524232 EED000031 -ELIANNA FLORIDO Active Y N A I D <br /> 3122-STORMWATER INSPECTION-AUTO SHOP PR0523063 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0528299 EE0009000-HARPRIT MATTU Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0535651 EE0007379-AMANDA BOERTIEN Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0534361 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENTS 1,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER cn this form. 1 also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State andror <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received by <br /> Eli Staff: Date 1 1 Account out: Date f 1 <br /> COMMENTS: Invoice#: <br />