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Date mn 4/30/2007 4:12:52PK SAN JG'^UIN COUNTY ENVIRONMENTAL HEA'—TA DEPARTMENT Report#5021 <br /> Runk Pagel <br /> - -~1 -. <br /> Facility Information as of 4130/20o. <br /> Record Selection Criteria: Facility ID FA0002111 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> EM OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0012990 New Owner ID <br /> Owner Name PORTILLO, A; KENDRICK,J <br /> Owner DBA <br /> Owner Address 3011 W BENJAMIN HOLT DR <br /> STOCKTON, CA 95219 <br /> Home Phone 209-477-1703 <br /> WorkBusiness Phone Not Specified <br /> Mailing Address 3011 W BENJAMIN HOLT DR <br /> STOCKTON, CA 95219 <br /> Care of PORTILLO,A; KENDRICK, J <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0002111 <br /> Facility Name BEN HOLT SHELL <br /> Location 3011 W BENJAMIN HOLT DR <br /> STOCKTON, CA 95219 <br /> Phone 209-477-1703 <br /> Mailing Address 3011 W BENJAMIN HOLT DR <br /> STOCKTON, CA 95219 'S <br /> Care of PORTILLO,A; KENDRICK,J <br /> Location Code 01 -STOCKTON APN 10018010 <br /> BOS District 002- RUHSTALLER, LARRY SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003362 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner I Facility I Account <br /> Account Name BEN HOLT SHELL (circle One) <br /> Account Balance as of 4/30/2007: $595.50 <br /> (Circle One) <br /> Tfanster to Acfiva/Inactve <br /> Program/Element and Desalptim Record ID Employee ID and Name Status New Owner? Delete <br /> 1615-RETAIL MKT<2000 SO FT (PREPKGD/LTCPRO163276 EE0003361 -MARIBEL FLOHRSCHU Active Y N A I D <br /> 222 -SM HW GEN<5 TONS/YR PR0513717 EE0009155-TOUA YANG Active Y N A D D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0511522 EEOOO0000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0519481 EE0000000-HAZ MAT SJC CES Active Y N A I D <br /> 2301 -UST STATE SURCHARGE FEE PR0515540 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2351 -UST FACILITY-2481 COMPLIANT PR0231883 EE0009155-TOUA YANG Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARFIR0506655 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0522828 EE0004636-GARRETT BACKUS 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 <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 Ordinate Codes ardVor Standards and <br /> State andror Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: "$372.00= Amount Paid Date <br /> Payment Type Check Number Recei <br /> REHS: lid w Date / �_/�Z Account out: Date <br /> COMMENTS: I c— V - <br /> 61-7 <br /> ��� <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />