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Date run a 9/22/2014 4:37:58PR SAN JN COUNTY ENVIRONMENTAL HEA4&EPARTMENT Report#5021 <br /> Run by >t Pagel <br /> Facility Information as of 9/22/2014 <br /> Record Selection Criteria: 7aulity ID FA0005287 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br /> Owner ID OW0015119 New Owner ID <br /> Owner Name DELTA TRANSPORT INC <br /> Owner DBA <br /> Owner Address 15135 W EIGHT MILE RD <br /> STOCKTON, CA 95219 <br /> Home Phone 925-890-5099 <br /> Work/Business Phone 209-951-4634 <br /> Mailing Address 41rQ6WElGIITMI6Fn RID IS64#19FERRYi r 1;h MA <br /> A-vi*--, Y? r A9 4SO <br /> care of J <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility lD/CERS ID FA0005287 10181789 <br /> Facility Name H & H MARINA <br /> Location 15135 W EIGHT MILE RD <br /> STOCKTON, CA 95219 <br /> Phone 209-951-4634 x <br /> Mailing Address 15135 W EIGHT MILE RD <br /> STOCKTON, CA 95219 117A ISO <br /> Care of JOHNSON, DAVE <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 06908021 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION ( C / /ZD <br /> Account ID AR0005748 New Account ID: <br /> Mail Invoices to Facility fk"u< Mail Invoices to: Owner / Facility / Account <br /> Account Name H & H MARINA Y-„e-�4A) b N I (Circle One) <br /> Account Balance as of 9/22/2014: $250.00 1 (� <br /> 7 Circle One) <br /> Transfer to Activellnectve <br /> Program/Element and Desorption Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO519562 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0516679 EE0001422-ARTS VELOSO Inactive Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO611629 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2226-CaIARP PROGRAM PRO514568 EEoo00000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PRO501969 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO509341 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2832-AST FAC 10 K-</=100 K GAL CUMULATIVE PRO516678 EE0001422-ARIS VELOSO Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532787 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 specific,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form, Ialso certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and Stale andor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE PS �1t-✓D�Ct.C� 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 Receive by <br /> REHS: Date—/ / Account out: Date 2 <br /> COMMENTS: <br /> Mo.:t� re- "n —Tease <br />