Laserfiche WebLink
Report U5021 <br /> Date run 3/7/2013 1:21:31PM SAN JO, UIN COUNTY ENVIRONMENTAL HEAI`I DEPARTMENT Fege <br /> Run by jolly Facility Information as of 3/7/2013 <br /> Record Selection Criteria. Facility ID FA0012236 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0009485 New Owner ID <br /> Owner Name KELLEY, JOE N II <br /> Owner DBA KELLEY BROS BREWING CO <br /> Owner Address 6825 ZERILLO DR <br /> RIVERBANK, CA 95367 <br /> Home Phone 209-604-6574 <br /> Work/Business Phone Not Specified <br /> Mailing Address 6825 ZERILLO DR <br /> RIVERBANK, CA 95367 <br /> Care of JOE N KELLEY II <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012236 <br /> Facility Name KELLEY BROS BREWING CO <br /> Location 112 E YOSEMITE AVE <br /> MANTECA, CA 95336 <br /> Phone 209-825-1727 <br /> Mailing Address PO BOX 2466 <br /> MANTECA, CA 953361165 <br /> Care of KELLEY BROS BREWING CO <br /> Location Code 04-MANTECA Alt Phone <br /> BOS District 005 -ORNELLAS, LEROY Fax <br /> APN 22102033 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name KELLEY BROS BREWING CO <br /> Title <br /> Day Phone 209-825-1727 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0019762 New Account ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name KELLEY BROS BREWING CO (Circle One) <br /> Account Balance as of 3/7/2013: $0.00 <br /> (Circle One) <br /> Transferto Activellnictve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1626-RESTAURANT/BAR 101 +SEATS PR0516586 EE0003474-CHANDRA OM Inactive Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0522268 EE0002474-MICHAEL PARISSI Active Y N A (D D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO517788 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARCPR0517789 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PRO533982 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project spedtic,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this forth I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and'or Standards and State ander <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / I <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 Remit y <br /> SS: �- d� Date /�/� Account out: Date / /� <br /> TS: 3 � ? 1i3 <br /> NO 13 �� <br />