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Date run 12/3/2008 8:45:57AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/3/2008 <br /> Record Selection Criteria: Facility 1D FA0013927 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0011015 New Owner ID <br /> Owner Name BACKLUND, DALE <br /> Owner DBA DOW <br /> Owner Address 400 W GANDY DANCER <br /> TRACY, CA 95377 <br /> Home Phone 209-836-4440 <br /> Work/Business Phone Not Specified <br /> Mailing Address 400 W GANDY DANCER <br /> TRACY, CA 95377 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013927 <br /> Facility Name DOW <br /> Location 400 W GANDY DANCER <br /> TRACY, CA 95377 <br /> Phone <br /> Mailing Address 400 W GANDY DANCER <br /> TRACY, CA 95377 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 24803002 Entail : <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name DALE BACKLUND <br /> Title / <br /> Day Phone 209-836-4440 x3019 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATIO.N/p <br /> Account ID AR0023512 f/(`5 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name URS (Circle one) <br /> Account Balance as of 12/3/2008: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Des= Record ID Employee ID and Name New Owner? delete <br /> 2960-RWQCB SITE PR0518474 EE0000684-MICHAEL INFURNA ZInve Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anpecific,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: 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 Receive <br /> REHS: Date Account out: Date <br /> COMMENTS: <br /> \\ph s-eh sq I-n t\apps\envisions\re ports\5021.rpt <br />