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Date run 10/18/2007 9:42:34A SAN JOIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/18/2007 <br /> Record Selection Criers: Facility ID FA0007013 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0005765 New Owner ID <br /> Owner Name HEADWATERS RESOURCES <br /> Owner DBA FORMER KOPPEL STKN TERMINAL <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 ID FA0007013 <br /> Facility Name HEADWATERS RESOURCE/FMR KOPPEL <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 APN:14503006 <br /> BOB District 001 - GUTIERREZ, STEVE SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION a� G <br /> Account ID AR0010069 3 / / ! " New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CH2M H NC / (Circle One) <br /> Account Balance as of 10/18/2007. $0.00 V/ <br /> (Circe One) <br /> Transfer to gctive/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Omen Delete <br /> 2960-RWQCB SITE PRO505804 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 speck,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this fame. I also certify 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 /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />