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Date run 7/5/2007 11:33:23AM SAN JO.JW COUNTY ENVIRONMENTAL HEAJO)EPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 7/5/2007 <br />Record Selection Criteria: Facility ID FA0018291 <br />OWNER FILE INFORMATION <br />Owner ID OW0002055 <br />Owner Name CALIFORNIA ARMY NATIONAL GUARD <br />Owner DBA CALIF NATIONAL GUARD <br />Owner Address 9800 GOETHE RD <br />SACRAMENTO, CA 958273563 <br />Home Phone 916-854-3334 <br />Work/Business Phon <br />Mailing Address PO BOX 269101 <br />SACRAMENTO, CA 958269101 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID FA0018291 <br />Facility Name FMS #24 (OMS) <br />Location 8020 S AIRPORT WAY <br />STOCKTON, CA 95206 <br />Phone <br />Make changes/corrections in RED ink or pencil. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />New Owner ID <br />�N ✓! R.a ,w�iv//T�i G �F G E <br />Mailing Address on RQX 2691 Q1 /iL�20 /�4, (lG� <br />s <br />c co G <br />Location Code 99 - UNINCORPORATED AREA APN: <br />BOS District 001 - GUTIERREZ, STEVE SIC Code: <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0032217 <br />Mail Invoices to Facility <br />Account Name FMS #24 (OMS) <br />Account Balance as of 7/5/2007: $95.00 <br />Program/Element and Description Record ID Employee ID and Name <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Status New Owner? Delete <br />2957 - UST FILE - RWQCB PRO526994 EE0000684 - MICHAEL INFURNA Active 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 <br />facility 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 Ordinace Codes and/or Standards and <br />State and/or Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be T NSFERED: ` $20.00 = Amount Paid Date <br />Water System to be T S RED: " $372.00 = Amount Paid Date <br />Payment Type Check Number Received by <br />REHS: Date / / Account out: Date <br />COMMENTS: <br />\\phs-ehsq I-nt\apps\envisions\re ports\5021. rpt <br />