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Daterun 4/23/2013 9:39:01AN SAN JO1�[N COUNTY ENVIRONMENTAL HEAL�EPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility information as of 4/23/2013 <br /> Record Selection Criteria: Facility ID FA0009948 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> I,(AX1/� OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0007948 Case Number: H05977 New Owner ID <br /> Owner Name A&A ROSSI HAY SERVICE <br /> Owner DBA <br /> Owner Address-511 N A'RP6RT-FIVAY D.q j AA/ <br /> MANTECA, CA 95336 <br /> Home Phone 209-609-6954 <br /> Work/Business Phone 209-823-3965 <br /> Mailing Address PO BOX 332 <br /> MANTECA, CA 95336 <br /> Care of A&A ROSSI HAY SERVICE <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0009948 10,183,053 <br /> Facility Name A&A ROSSI HAY SERVICE <br /> Location 641 N AIRPORT Yi ��a <br /> MANTECA, CA 95336 <br /> Phone 209-823-3965 <br /> Mailing Address PO BOX 332 <br /> MANTECA, CA 95336 <br /> Care of <br /> Location Code 04- MANTECA Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 19816021 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> AccountlD AR0016948 New Account ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name A&A ROSSI HAY SERVICE (Circle One) <br /> Account Balance as of 4/23/2013: $6,566.10 <br /> (Circle One) <br /> Transferto Activelnacwe <br /> Pmgram/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO519980 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PRO514106 EE0002646-THUY TRAN Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0512236 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0509948 EEOOD0000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2832-AST FAC 10 K-</=100 K GAL CUMULATIVEPRO515679 EE0002646-THUY TRAIN Active Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO535794 EE0007379-AMANDA BOERTIEN Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCKPR0531871 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge Net all site,andror project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billetl to the party identified as the OWNER on this forth I also cartgy that all operations will be performed in accordance with all applicable Ordinance Codes andior Standards and State andbr <br /> Federal Laws. <br /> APPLICANTS 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 b <br /> REN�S: <br /> � �/ �`y ,fls Date [�Jf✓W,/.7�/� Account out: Date / 3 //-3 <br /> COMMENTS: Wl..4sA l(�. <br /> R 11 � <br />