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FRunby <br /> 2/10/2016 10:31:47AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Facility Information as of 2/10/2016 Pagel <br /> Record Selection Criteria. Fadaty ID FA0015131 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br /> Owner ID OW0008258 New Owner ID <br /> Owner Name <br /> Owner DBA rr'�^ <br /> T .S` c r i o O <br /> Owner Address 23737 S CHRISMAN RD �r« <br /> TRACY, CA 95376 <br /> Home Phone Not Specified �oF-7 ttSOS S9�' 7 <br /> Work/Business Phone z-69 .38_ Za 4 SSS /YJ/� <br /> Mailing Address pew-11-52 <br /> �„2 [ <br /> TRAGY, GA 96378452— �i^��.� �,14 I: -E376 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0015131 <br /> Facility Name TgRlli�Ec ccEvi-R— <br /> Location 23737 S CHRISMAN RD <br /> TRACY, CA 95376 <br /> Phone Y'E83"6�8- 22t'79 SCS�S'/a/�s <br /> Mailing Address -J+&2-., / �S 2 c-j ( / � S.� T 2.S 9 <br /> lA J�i3 7 <br /> Care of Sc o p <br /> Location Code 99-UNINCORPORATED P Alt Phone <br /> BOS District 005- ELLIOTT, BOB Fax <br /> APN 250-140-13 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 AR0025956 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name RAY BORGES (Circe One) <br /> Account Balance as of 2/10/2016: $0.00 <br /> (Circe One) <br /> Transfer to Activellnal <br /> PrograMElement and Description Record ID Employee ID and Name Status New Chance? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO522281 EE0000010-PETER LOMBARDI Inactive Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO522209 EE0002646T'-'".�.,vY-.....Te^"' t/ie ty ry, Inactive -C:!t� N-Il D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534229 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 s,,l PHSEHD hourly charges associated with this facility <br /> or activity will be billetl to the party identfied as the OWNER on this form. I also certify that all operations will be pertomed in accordance with all applicable Ordinance Codes anclor Standards and State and'or <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date / I <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / I <br /> Water System to be TRANSFERED: Amount Paid Date / / <br /> Payment Type Check Number Received by <br /> EHD Staff: Date Account out: Date / / <br /> COMMENTS: Invoice#: <br /> 2 Z 1,D <br /> 1.372,2, <br />