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Date run 6/30/2004 9:09:OOAN SAN JCOUNTY ENVIRONMENTAL HEAq DEPARTMENT Report #5021 <br />Run by++ Pagel <br />Facility Information as of 6/30/2004 <br />Record Selection Criteria: Facility ID FA0013902 <br />OWNER FILE INFORMATION <br />Owner ID OW0010994 <br />Owner Name HERNANDEZ, GILBERTO <br />Owner DBA HERNANDEZ APPLIANCE <br />Owner Address <br />Home Phone 209-367-1397 <br />Work/Business Phone Not Specified <br />Mailing Address <br />Care of GILBERTO HERNANDEZ <br />FACILITY FILE INFORMATION <br />FacilityID <br />FA0013902 <br />FacilityName <br />HERNANDEZ APPLIANCE <br />Location <br />1340 S HUTCHINS ST <br />LODI, CA 95240 <br />Phone <br />209-367-1397 <br />Mailing Address 1340 S HUTCHINS ST <br />LODI, CA 95240 <br />Care of GILBERTO HERNANDEZ <br />Location Code 02 -LODI <br />BOS District <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0023440 <br />Mail Invoices to Facility <br />Account Name HERNANDEZ APPLIANCE <br />Account Balance as of 6/30/2004: $0.00 <br />ProgramlElement and Description <br />2217 - APPLIANCE RECYCLER <br />Record ID Employee ID and Name <br />Make changes/corrections in RED ink or pencil. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />New Owner ID <br />APN:04513038 <br />SIC Code: <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/InactVa <br />Status New Owner? Delete <br />PR0518429 EE0008389 - DENNIS CATANYAG Active Y N A W D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of some, acknowledge that all site, andlor project specific, PHS/EHD hourly charges associated with this <br />facility or activitywill be billed to the parry Identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinate Codes and/or Standards and <br />State and/or Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date / <br />Program Records to be TRANSFERED: " $20.00 = Amount Paid Date <br />Water System to be TRANSFERED: " $155.00 = Amount Paid Date / / <br />Payment Type Check Number Received by <br />REHS: D\%� Date OU /ack /0�k_ Account out: !0 Date /to/ <br />COMMENTS: <br />\\Phs-ehsq I-nt\apps\Envisions\Reports\5021.rpt <br />