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SAN Jr Report f/5021 <br />Date mn 2/28/2011 1:15:28Pr. '2UIN COUNTY ENVIRONMENTAL HE, "H DEPARTMENT <br />Run by `/• <br />Pagel <br />Facility Information as of 9J28/2aTR <br />Record Seleddon Criteria: Fadity to FA0014414 <br />OWNER FILE INFORMATION <br />Owner ID OW0011456 <br />Owner Name <br />PACIFIC STATE BANK <br />Owner DBA <br />RABOBANK N A <br />Owner Address <br />635 AURORA ST <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-g?0-5*?+ <br />Mailing Address <br />-9Q44AE SJWD <br />AT44ERSQW,-CA —"&27 <br />Care of <br />KE.NQnl I RATFS <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0014414 <br />Facility Name <br />FORECLOSED PROPERTY <br />Location <br />635 AURORA ST <br />STOCKTON,CA 95203 <br />Phone <br />209,�,n'. <br />Mailing Address <br />$999-W-NhillAQUN <br />OC 7 <br />Care of <br />1'(ENOM BATES <br />Location Code <br />01 - STOCKTON <br />BOS District <br />001 - VILLAPUDUA <br />APN <br />14730004 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name KENDAU BATES <br />Title <br />Day Phone 209-870-3221 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0024494 <br />Mail Invoices to Facility <br />Account Name FORECLOSED PROPERTY <br />Account Balance as of 2/28/2011: $262.00 <br />Program/Element and Description <br />Record ID Employee ID and Name <br />Make changes/correctlons in RED ink. rf Q <br />INFORMATION CHANGE (date) 2 Z$ <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Wrsziiic�fl, <br />1 1 a ��• � <br />7 - <br />�l <br />Fax <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Girds One) <br />(Circle One) <br />Transfer to Active/InacNe <br />Status New Owner? Delete <br />2220 - SM HW GEN <5 TONS/YR PRO528613 EE0001421 - STACY RIVERA Active Y N A I D <br />2244 - PACT TRANSFER RECORD - IDES PR0519272 EE0000000 - HAZ MAT SJC DES Inactive Y N A 1 D <br />ERSC - ELECTRONIC REPORTING STATE SURCHPR0533763 Active Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specfic, PHS/EHD hourty charges associated wdh this <br />facility or activity will be billed to the parry identified as the OWNER on this form. I also certify that all operations will be performed in accordance wah all applicable Ordinate Codes and/or Standards and <br />State andfor Feaeral Laws. <br />APPLICANTS SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment T Check Number <br />REHS: f <br />COMMENTS <br />\\eh-env\envision\reports\5021. rpt <br />Date <br />$25.00 = Amount Paid Date // <br />Amount Paid Date / <br />Recall ,�L//- <br />Date Z91–(,j Account out: Date / / *V <br />