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r',- 4 <br />Date run 6/18/2004 9:34:45AA <br />Run by SAN JOA(t .N COUNTY Ef, VI.RONMENTAL HEALTH DEPARTMENT <br />Facility Information as of 6/18/2004 <br />Record Selection Criteria: Facility ID FA0007491 <br />Make changes/corrections in RED ink or pencil. <br />INFORMATION CHANGE (date) <br />OWNER FILE INFORMATION OWNERSHIP CHANGE (date) <br />Owner ID <br />OW0006188 <br />Owner Name <br />&tt-, StJKI`IBINDAR & KAMAL <br />Owner DBA <br />TRUCK WASH OF STOCKTON <br />Owner Address <br />16990 MCGILL RD <br />Phone <br />SAR,ATOGA—CA -950% <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />408-741-5451 <br />Mailing Address <br />2539_GIMELLI-GT APT -53 <br />Location Code <br />5AN_JO.SE—C"- 51332653, <br />Care of <br />001 - GUTIERREZ, STEVE <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0007491 <br />Facility Name <br />COUNTRY MARKETPLACE TRUCK WASH <br />Location <br />1524 FRESNO AVE <br />PR0516168 <br />'361 - NEW MULTI UST FACILITY <br />STOCKTON, CA 95206 <br />Phone <br />209_933-3260 <br />Mailing Address <br />2.6 g IMEEL+-C-T—APT-63 <br />SAN-JOSE—,CA-951332653— <br />Care of <br />Location Code <br />01-STOCKTON <br />BOS District <br />001 - GUTIERREZ, STEVE <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0011647 <br />Mail Invoices to Facility <br />Account Name COUNTRY MA ETPLACE TRUCK WASH <br />'account Balance as of 6/18/2004: $1, 00 <br />'rogram/Element and Description Record ID Employee ID and Name <br />NewOwnerlD :fftV1V#q'7 <br />r Y <br />Report #5021 <br />Pagel <br />Cf -9 • C ha rtE r W <br />-�fcckU-0VIJ C41t+ 45' o <br />1-1 J' - Q 4i • C d r -4-Q r Lu <br />-:�) IncA Ja' n Ca 1 oy <br />— L 7— � �?' C �hc: I V �A*—' ( -& � � <br />APN:16337025 <br />SIC Code:9900 <br />New Account I D: <br />Mail Invoices to: Owner <br />'_220 - SM HW GEN <5 TONS/YR PR0518517 <br />'.224 <br />EE0008844 - DINA ABATE <br />- HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0513176 <br />EE0000000 - HAZ MAT SJC OES <br />'244 - PACT TRANSFER RECORD - OES PR0521056 <br />'.301 - UST STATE SURCHARGE <br />EE0000000 - HAZ MAT SJC OES <br />PR0516168 <br />'361 - NEW MULTI UST FACILITY <br />EE0008317 - RAYMOND VON FLUE <br />PR0506545 <br />'399 - UNIFIED PROGRAM FAC STATE SERVICE FPR0507670 <br />EE0008844 - DINA ABATE <br />EE0008317 - RAYMOND VON FLUE <br />Status <br />Active <br />Active <br />Active <br />Inactive <br />Active <br />Inactive <br />Facility / Account <br />(Circle One) 4 <br />Transfer to (Circle One) <br />Active <br />New Owner? Delete ve <br />Y N A I D <br />Y N A I D <br />Y N A I D <br />Y N A I D <br />Y N A I D <br />Y N A I D <br />ILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this <br />icility 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 Ordinate Codes and/or Standards and <br />tate and/or Federal Laws. <br />PPLICANT'S SIGNATLOE: <br />_ Date <br />rogram Records to be TRANSFERED: * $20.00 = Amount Paid134,1 <br />/ater System to be TRANSFERED: $155.00 Amount Paid Date <br />* = Date / <br />ayment Type ✓ Check Number f Re e' by / <br />EHS: _ y� p� <br />DMMENTS: " Date _ J /_�/ (fit{ Account out: —�� Date <br />-L t- <br />-CF-1V <br />'P,`kR (-r ��k 1 D. l � i f D �-o l �l�l l� RFC <br />JUNl $ 2004 <br />' hs-ehsql-n t\apps\Envisions\Reports\5021. rpt <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />