Laserfiche WebLink
Date run 12/23/2014 4:19:51P SAN JOAQUIN COUNTY ENVIRONMENTALHEALTH DEPARTMENT <br /> _Ron Report#5021 <br /> Y <br /> Facility Information as of 12/23/2014 Pagol <br /> Record Selection Criteria: Facility ID FA0022717 <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: 1 SSN/Fed Tax ID <br /> Owner ID OW0020454 New Owner ID <br /> Owner Name Richard Thompson <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-639-1583 <br /> Mailing Address 7603 S. Jack Tone Rd <br /> Stockton, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0022717 10602265 <br /> Facility Name Collegeville <br /> Location 8499 S JACK TONE RD <br /> Stockton, CA 95215 <br /> Phone 209-639-1583 x <br /> Mailing Address 7603 S. Jack Tone Rd. <br /> Stockton, CA 95215 <br /> Care of Richard Thompson <br /> Location Code Alt Phone <br /> BOIS District Fax <br /> APN Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0041616 New Account ID: <br /> Mail Invoices to Account Mail Invoices to Owner / Facility / Account <br /> Account Name Richard Thompson (Circle One) <br /> Account Balance as of 12/23/2014: $0.00 <br /> (Circle One) <br /> Transfer to Activishil <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,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 on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes spoor Standards and State andfor <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 by <br /> REHS: \NN Date_�/ ` �l / 1 Account out: Date <br /> COMMENTS: <br /> �,,yyC MF(L Anti-0 "0 VRocriRArn Fc� RPSA , <br />