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Date run 8/25/2015 8:57:09AA SAN J -1IN COUNTY ENVIRONMENTAL HE '-i DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 8/25/20,,j <br />Record Selection Criteria: Facility ID FA0020842 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0017135 <br />Owner Name <br />JAZZ GROUP INC <br />Owner DBA <br />Owner Address <br />17608 ALMOND ORCHARD AVE <br />LATHROP, CA 95330 <br />Home Phone <br />916-470-5520 <br />Work/Business Phone <br />209-239-8111 <br />Mailing Address <br />17608 ALMOND ORCHARD AVE <br />LATHROP, CA 95330 <br />Care of <br />SINGH, MANJEET <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0020842 10187697 <br />Facility Name IMPERIAL TRUCK & TRAILER REPAIR <br />Location 2142 W YOSEMITE AVE <br />MANTECA, CA 95337 <br />Phone 209-239-8111 <br />Mailing Address 2142 W YOSEMITE AVE <br />MANTECA, CA 95337 <br />Care of SINGH, MANJEET <br />Location Code 04 - MANTECA <br />Bos District 005 - ELLIOTT, BOB <br />APN 24130058 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Make changes/corrections in RED ink. I _ <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Contact Name MANJEET SINGH <br />Title <br />Day Phone 209-239-8111 <br />Night Phone 916-470-5520 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0037431 <br />New Account ID: <br />Mail Invoices to Facility <br />Mail Invoices to: <br />Owner / <br />Facility / <br />Account <br />Account Name IMPERIAL TRUCK & TRAILER REPAIR <br />(Circle One) <br />Account Balance as of 8/25/2015: $0.00 <br />(Circle One) <br />Transfer to <br />Active/Inactve <br />Program/Element and Description <br />Record ID <br />Employee ID and Name <br />Status <br />New Owner? <br />Delete <br />1921 - HMBP-Reqular-Primary Location <br />PR0537272 <br />EE0002474 - MICHAEL PARISSI <br />Active <br />Y N <br />A <br />I D <br />2227 - GEN 5<25 TONS PERMIT <br />PR0536264 <br />EE0002646 - THUY TRAN <br />Active <br />Y N <br />A <br />I D <br />2831 - AST FAC >/= 1,320 - <10 K GAL CUMULATIVE <br />PR0536676 <br />EE0002646 - THUY TRAN <br />Active <br />Y N <br />A <br />I D <br />4740 - WASTE TIRE SITE - EXEMPT <br />PR0536675 <br />EE0009000 - HARPRIT MATTU <br />Active <br />Y N <br />A <br />I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG <br />PR0536277 <br />Inactive <br />Y N <br />A <br />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 and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: Date <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 Received by <br />EHD Staff: Date i l �- I ! 5 Account out: Date <br />COMMENTS: 1 1 - <br />n,\^,C-% ,.;, �Tj-;J Invoice#: <br />O oc' S (a—s-e— b \ `lL <br />