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Date mn 7/6/2010 9:10:50AM SAN JOAN C00131'QTY ENVIRONMENTAL HEALIDDEPARTMENT Report#5021 <br /> Paget <br /> Run by <br /> Facility Information as oll 7/6/201 <br /> Record Selection Criteria: Facility ID FA0018766 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0015433 New Owner ID <br /> Owner Name SANCHEZ, MANNY <br /> Owner DBA SMOG PRO <br /> Owner Address 1904 MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> Home Phone 209-467-4198 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1904 MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0018766 <br /> Facility Name SMOG PRO <br /> Location 2088 E MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> Phone 209-467-4198 <br /> Mailing Address 2088 E MARIPOSA RD <br /> STOCKTON, CA 95205 <br /> care of SANCHEZ, MANNY <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 17304034 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SANCHEZ, MANNY <br /> Title <br /> Day Phone 209-467-4198 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0033314 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility I Account <br /> (Circle One) <br /> Account Name PSI <br /> Account Balance as of 7/6/2010: $0.00 (Circle one) <br /> Transferto Active/Inacroe <br /> Program/Element and Description <br /> Record ID Employee ID and Name Status New Owner/ Delete <br /> 2950-ENVIRON ASSESS PR0527692 EE0000997-HARLIN KNOLL Active 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: S e 2 —4&iNt ' �+�. �` Date / b -/k b <br /> Program Records to be TRANSFERED: '$20.00= Amount Paio..E% _ Date <br /> Water System to be TRANSFERED: _*$372.00= Amount Paid Date <br /> Payment Type ✓ Check Number y 5 S Received by <br /> REHS: Date /_/ Account out: Date /_/_ <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />