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Date run 12/3/2012 4:19:25PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Reportill <br /> Run by Pagel <br /> Facility Information as of 12/3/2012 <br /> Rece,d Selection Criteria: Facility ID FA0020783 <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 lD OW0017086 New Owner ID <br /> Owner Name COFFEY, CHRIS <br /> Owner DBA CONSTRUCTION PROTECTIVE SERVIC <br /> Owner Address 436 W WALNUT ST <br /> GARDENA, CA 90248 <br /> Home Phone 310-818-1030 <br /> Work/Business Phone Not Specified <br /> Mailing Address 436 W WALNUT ST <br /> GARDENA, CA 90248 <br /> Care of VERA, LUIS <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0020783 <br /> Facility Name CONSTRUCTION PROTECTIVE SERVICES <br /> Location 816 N SACRAMENTO ST <br /> LODI, CA 95240 <br /> Phone 310-818-1030 <br /> Mailing Address 436 W WALNUT ST <br /> GARDENA, CA 90248 <br /> care of LUIS VERA <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 04118004 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name CHRIS COFFEY <br /> Title OWNER <br /> Day Phone 310-818-1030 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0037302 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name CONSTRUCTION PROTECTIVE SERVICES (Circle One) <br /> Account Balance as of 12/3/2012: $268.00 <br /> (Circle One) <br /> Transfer to Adwalinal <br /> PrograMElement and Description Record ID Employee ID and Name Status New OwneR Delete <br /> 4244-PUMPER TRUCK PR0536165 EE0005944-MICHAEL ESCOTTO A lve Y N A D <br /> 4246-PUMPER YARD PR0536166 EE0005944-MICHAEL ESCOTTO A7te Y N A D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I.Me undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges assouated with this facility <br /> or aliry will be billed to the party identified as Me OWNER on this form I also certify that all operations will be pertomred in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws. —}� <br /> APPLICANTS SIGNATURE: S«- �✓/ Date �� l 3 / 1.2— <br /> Program <br /> ZProgram Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment T Check N bar Receive by <br /> RENS: Wim^ Date / /�Aecount out: Date Z/�/�. <br /> COMMENT <br />