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Datemn 8/4/2010 9:20:31AM SAN JUIN COUNTY ENVIRONMENTAL HEW DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/412 u <br /> Record Selection Criteria: Facility ID FA0010980 <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 OW0008980 Case Number: H09098 New Owner lD <br /> Owner Name GARY&LYNNE BROCK <br /> Owner DBA G&L BROCK CONSTRUCTION CO INC <br /> Owner Address 4145 CALLOWAY CT <br /> STOCKTON, CA 952152400 <br /> Home Phone Not Specified <br /> Work/BusinessPhone 209-931-3626 <br /> Mailing Address 4145 CALLOWAY CT <br /> STOCKTON, CA 952152400 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010980 <br /> Facility Name G&L BROCK CONSTRUCTION CO INC <br /> Location 4145 CALLOWAY CT <br /> STOCKTON, CA 952152420 <br /> Phone 209-931-3626 <br /> Mailing Address 4145 CALLOWAY CT <br /> STOCKTON, CA 952152400 <br /> Care of <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 002- RUHSTALLER, LARRY Fax <br /> APN 087-220-04 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017980 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name G&L BROCK CONSTRUCTION CO INC (Circle One) <br /> Account Balance as of 8/4/2010: $0.00 <br /> (Circle One) <br /> Transfer to Active/lnecha <br /> Program/Element and Description Record ID Employee 10 and Name status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO514480 EE0004636-GARRETT BACKUS Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513268 EEOO0000O-HAZ MAT SJC IDES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PRO520586 EEOOOOOOO-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPRO510980 EEOO00000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PR0532623 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party Identified as Me OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Date ! / <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Receive <br /> REHS: Date l 2/0 l /C? Account out: Date <br /> COMMENTS: <br /> Mcg39 <br /> \\eh-env\envision\reports\5021.rpt <br />