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Date run 9/3/2013 1:40:45PM SAN JOHN COUNTY ENVIRONMENTAL HEADEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/3/2013 <br /> Record Selection Criteria: Facility ID FA0007013 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0005765D� New Owner ID <br /> Owner Name 5Toi OF ( �lS7kacT <br /> Owner DBA FORMER KOPPEL STKN TER INAL <br /> Owner Address 2025 W HAZELTON AVE <br /> STOCKTON, CA 95203 <br /> Home Phone 209-469-0625 <br /> Work/Business Phone Not Specified <br /> Mailing Address 2025 W HAZELTON AVE <br /> STOCKTON, CA 95203 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0007013 <br /> Facility Name /FMR KOPPEL$7b4IF7D itO E L <br /> Location 2025 W HAZELTON AVE <br /> STOCKTON, CA 95203 <br /> Phone 209-469-0625 <br /> Mailing Address 2025 W HAZELTON AVE <br /> STOCKTON, CA 95203 <br /> Care of <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOIS District 001 -VILLAPLIDIJA Fax <br /> APN 14503006 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone 209-469-0625 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0010069 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CH2MHILL/ RDD l (CircleGne) <br /> Account Balance as of 9/3/2013: $-366.00 65p-/.�1/� <br /> W Q r—`x `t I (Circle One) <br /> 3 Transfer to Aclivellnactve <br /> Progra"Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2960-RWOCB SITE PR0505804 EE0000684-MICHAEL INFURNA 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,PHSIEHD hourly charges associated with this facility <br /> 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 Ordinance Codes andor Standards and State ani <br /> 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 /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />