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Date run 7/6/2010 11:54:24AM SAN JOAN COUNTY ENVIRONMENTAL HEAL*EPARTMEITt Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/6/2010 <br /> Record Selection Cdtena: Facility ID FA0012153 <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 OW0001165 New Owner ID <br /> Owner Name CITY OF STOCKTON <br /> Owner DBA <br /> Owner Address 305 N EL DORADO ST STE 200 <br /> STOCKTON, CA 95202 <br /> Home Phone 209-465-4528 <br /> Work/Business Phone 209-946-9222 <br /> Mailing Address 22 E WEBER AVE#350 <br /> STOCKTON, CA 95202 <br /> Care of CITY OF STOCKTON <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012153 <br /> Facility Name SOUTH SHORE PARCEL <br /> Location WEBER AVE <br /> STOCKTON, CA 95202 <br /> Phone <br /> Mailing Address 22E WEBER AVE #350 <br /> STOCKTON, CA 95202 <br /> Care of KITTY WALKER <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SUE BRAUSE <br /> Title PRINCIPAL ANALYST <br /> Day Phone 209-937-8840 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0019491 X0�� NewAccount ID: <br /> Mail Invoices to Account.-I` 5 Mail Invoices to: Owner / Facility / Account <br /> Account Name SOUTH SHORE PARCEL (CirdeOne) <br /> Account Balance as of 7/6/2010: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Omen Delete <br /> 2960-RWQCB SITE PR0515450 EE0003611 -FRANK GIRARDI 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,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identfied as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinary Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS 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 />