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Date run 5131!2005 2:54:57PN SAN!t 2UIN COUNTY ENVIRONMENTAL HE.~� 'H DEPARTMENT Report#5021 <br /> Run by / so-t Pagel <br /> Facility Information as of 5/31/2005 <br /> Record Selection Criteria: Facility ID FA0012021 <br /> Make changestcorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0009318 New Owner ID <br /> Owner Name WESTERN SQUARE INDUSTRIES INC <br /> Owner DBA <br /> Owner Address 1621 N BROADWAY <br /> STOCKTON, CA 95205 <br /> Home Phone 209-944-0921 <br /> WorklBusiness Phone Not Specified <br /> Mailing Address 1621 N BROADWAY <br /> STOCKTON, CA 95205 <br /> Care of WESTERN SQUARE INDUSTRIES INC <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012021 <br /> Facility Name WESTERN SQUARE INDUSTRIES INC <br /> Location 1621 N BROADWAY AVE <br /> STOCKTON, CA 95205 <br /> Phone 209-944-0921 <br /> Mailing Address 1621 N BROADWAY AVE <br /> STOCKTON, CA 95205 <br /> Care of <br /> Location Code 99 - UNINCORPORATED AREA APN: <br /> BOS District 001 - GUTIERREZ, STEVE SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0019074 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner ! Facility ! Account <br /> Account Name WESTERN SQUARE INDUSTRIES INC (Circle One) <br /> Account Balance as of 513112005: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramlFlement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 3030-UIC PROGRAM SITE PR0515035 EE0000684-MICHAEL INFURNA Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSlEHD 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 andlor Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date 1 / <br /> Water System to be TRANSFERED: `$155.00= Amount Paid Date 1 1 <br /> Payment Type Check Number Received by <br /> RENS: Date 1 1 Account out: Date 1 1 <br /> COMMENTS: <br /> tlphs-e hsq I-ntlappsle nvisio nslrepolts15021.rpt <br />