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Report#5021 <br /> E <br /> ;5/29/200;79:03:05AK SAN JOIN COUNTY ENVIRONMENTAL HEA DEPARTMENT pagoi <br /> 6 Facility Information as of 5/29120riteriFacility ID FA0016276 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> New Owner ID <br /> Owner ID OW0002824 <br /> Owner Name FOWLER, DON W <br /> owner DBA JIFFY LUBE#1478 (HAMMER) <br /> owner Address 1700 N BROADWAY <br /> WALNUT CREEK, CA 94596 <br /> Home Phone 209-957-8730 <br /> Work/Business Phone Not Specified <br /> Mailing Address 730 S BECKMAN RD STE B <br /> LODI, CA 95240 <br /> Care of BROADBASE INC dba JIFFY LUBE <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0016278 <br /> Facility Name JIFFY LUBE#1478 <br /> Location 1648 E HAMMER LN <br /> STOCKTON, CA 95210 <br /> Phone 209-957-8730 <br /> Mailing Address 730 S BECKMAN RD STE B <br /> LODI, CA 95240 <br /> Care of BROADBASE INC dba JIFFY LUBE APN:08818032 <br /> Location Code 01 -STOCKTON SIC Code:9900 <br /> BOS District <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> New Account ID: <br /> Account ID AR0028468 Mail Invoices to: Owner I Facility I Account <br /> Mail Invoices to Facility (circle one) <br /> Account Name JIFFY LUBE#1478 <br /> Account Balance as of 5/29/2007: $0.00 (Circle One) <br /> Transfer o Aclivellnactve <br /> ��� <br /> � <br /> Record ID Employee ID and Name Status NOW Omer? Delete <br /> Pro m m and Description Y N A I D <br /> -SM HW GEN<5 TONS/YR PR0524254 EE0008317-RAYMOND VON FLUE Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES <br /> PRO524482 Active <br /> dge that all <br /> ecific <br /> 121-113 hourly charges <br /> ociated With this <br /> BILLING <br /> or activity Will be billed to the ACKNOWLEDGEMENT. <br /> T 1 I theundersigned9 this former aper certify that all same, <br /> operanowte tions be performed site, <br /> accordance With ala pl6ble/Ordinace Codes ndtorsstantl ds and <br /> fac <br /> arty <br /> stale anmor Federal Laws. <br /> Date <br /> APPLICANTS SIGNATURE: <br /> Amount Paid Date <br /> Program Records to be TRANSFED: '720.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Received by <br /> Payment Type Check Number <br /> Date_l_I— Account out: <br /> RENS: Date�_l�1 D <br /> COMMENTS: <br /> /At X 3 9 0 <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />