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Date run 7/9/2009 1:56:04PM SAN J IN COUNTY ENVIRONMENTAL HEAL tr1EPARTMENT Report#5021 <br /> Pagel <br /> Run by Facility Information as of 7/9/2009 <br /> Record Selection Cnlena: Facility ID FA0019769 <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 OW0016220 New Owner ID <br /> Owner Name LIVAL PERTIES LTD <br /> Owner DBA <br /> Owner Address PO BOX 7576 —.--- <br /> STOCKTON, CA 95267 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 7576 <br /> STOCKTON, CA 95267 <br /> Care of KEYSER, DAN <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0019769 <br /> Facility Name FORMER SHELL GAS STATION <br /> Location 3011 W BENJAMIN HOLT DR <br /> STOCKTON, CA 95219 <br /> Phone <br /> Mailing Address PO BOX 7576 <br /> STOCKTON, CA 95267 <br /> Care of KEYSER, DAN <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 10018010 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 AR0035177 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CONE" VERS &ASSOCIATES ,t Circa One) <br /> Account Balance as of 7/9/200 : $-315.00 �r�� YE <br /> (Circe One) <br /> Transfer to Acl'rve/Inaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Omen Delete <br /> 2957-UST FILE-RWOCB PR0530063 EE0000684-MICHAEL INFURNA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,Ne 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 certil j that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> Stale and/or 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 Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />