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Date run 6/3/2015 11:42:40AM SAN JOIN COUNTY ENVIRONMENTAL HEAL EPARTMENT Report#5021 <br /> Run by Fall <br /> Facility Information as of 6/3/2015 <br /> Record Selection Criteria: Facility ID FA0010994 <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: 1 SSN/Fed Tax ID <br /> Owner ID OW0008994 Case Number: H09114 New Owner 10 <br /> Owner Name L BRET DEBERRY <br /> Owner DBA B&B TIRE& SERVICE <br /> Owner Address 39 N CLUFF AVE D <br /> LODI, CA 954240316 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-367-1875 <br /> Mailing Address 39 N CLUFF AVE STE D <br /> LODI, CA 954240316 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0010994 <br /> Facility Name B&B TIRE & SERVICE <br /> Location 600 W LOCKEFORD ST <br /> LODI, CA 95240 <br /> Phone 209-339-1916 x0 <br /> Mailing Address 39 N CLUFF AVE STE D <br /> LODI, CA 95424 <br /> Care of <br /> Location Code 02- LODI Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN 03723027 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017994 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name L BRET DEBERRY (Circle One) <br /> Account Balance as of 6/3/2015: $0.00 <br /> (Circle One) <br /> Transfer to Active/Ini <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO520594 EE0000000-HAZ MAT SJC OES k0l Y N A I D <br /> y)8220-SM HW GEN<5 TONS/YR PRO514487 EE0001422-ARTS VELOSOIn( actil Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0513282 EE0000000-HAZ MAT SJC OES Inactive Y N A 1 D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO510994 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO523244 EE5555555-Garrett Alias-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,ansor project specific,PHSIEHD hourly charges associated with this facility ori <br /> be billed to the party identified as the OWNER on this forth l also certify that all operations will be performed in accordance with all applicable Ordinance Codes and'or Standards and State ander Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date / / <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: <br /> Invoice#: <br />