Laserfiche WebLink
Date run 10/14/2015 9:50:02A SAN JOA'rJIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/14/2015 <br /> Record Selection Criteria: Facility ID FA0017042 <br /> Make changeslcorrections 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 OW0013883 New Owner ID <br /> Owner Name ROD DEMENT <br /> Owner DBA ROD DEMENT <br /> Owner Address 3761 BROOK VALLEY CIR <br /> STOCKTON, CA 95219 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 3761 BROOK VALLEY CIR <br /> STOCKTON, CA 95219 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0017042 10185799 <br /> Facility Name ROD DEMENT <br /> Location 1725 S HOLT RD <br /> STOCKTON, CA 95206 <br /> Phone 559-469-5146 x0 <br /> Mailing Address 3761 BROOK VALLEY CIR <br /> STOCKTON, CA 95219 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 13106005 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 AR0029924 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name ROD DEMENT (Circle One) <br /> Account Balance as of 10/14/2015: $505.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1958-HM-Farm Operations PR0525227 EE0009817-ROBERT LOPEZ Active Y N A ® D <br /> 2220-SM HW GEN<5 TONS/YR PR0530933 EE0001421 -STACY RIVERA Active Y N A D <br /> 2830-AST FAC -SPCC EXEMPT PR0530932 EE0001421 -STACY RIVERA Active Y N A D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532245 Inactive Y N A I D <br /> BILLING 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 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 and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: ) Date / I <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 b <br /> EHD Staff: d✓1 • /Vy+-L l-�� Date Iy l /y l��_ Account out: Date / l� <br /> COMMENTS: <br /> Invoice#: <br />