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J <br /> Date run 4/3/2014 1:13:57PM SAN- .QUIN COUNTY ENVIRONMENTAL HL,—CH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 4/3/2014 <br /> Record Selection Criteria: Facility ID FA0002805 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE (date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br /> Owner ID OW0002106 New,, ner ID <br /> Owner Name <br /> -PEA-RGEE,-JEF-F �k �533 <br /> Owner DBA \ CL <br /> Owner Address 1'6804f4DIAN VAL-L-EY-R-D 1 <br /> NaVATO--CA--94J47- - C <br /> Home Phones=6fl4=182'7 <br /> WorklBusiness Phone Not Specified U -A - Cl A <br /> Mailing Address 1-6-80-1NE)I-AN-V-AL-L--EY- RE) <br /> NOVAT-O-GA-94-94-7 C <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0002805 <br /> Facility Name REAR13f�7J-E1`FH-39=40 — <br /> Location 5125-S-KAISER--RD- rf� C3�L L <br /> STOC-K-T-ON;CA-952't0 cc�_ <br /> Phone 44-5-898-8052---_ <br /> Mailing Address t6801NDIAN-VALL_EY_ROAb 251�3,� �Q <br /> NOVATO,C-A-94947 <br /> Care of <br /> Location Code 99 - UNINCORPORATED A Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 18104006 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION I^ ^ <br /> Contact Name U-S-BANK-NNT-IONAL--A-SSN T-R <br /> Title <br /> Day Phone Offl- <br /> ACCOUNTS9m <br /> Night Phone RECEIVABLE FILE INFORMATION MAC 06 2014 <br /> Account ID AR0002366 V1VX0NtAEN1 H`ES New Account ID: <br /> Mail Invoices to Facility fVA\JI VIIIISERV Mail Invoices to: Owner / Facility / Account <br /> Account Name DEAR-CE�EFF H--39=40 (Circle One) <br /> Account Balance as of 4/3/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2765-EMPLOYEE HOUSING-PERMANENT>180 DAYS PR0270040 EE0008987-SCOTT SANGALANG Active Y N A I D <br /> 4630-NTNC WATER SYSTEM WA0461354 EE0005838-ADRIENNE ELLSAESSER Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner„orator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also ertif that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State andror <br /> Federal Laws. I 1 <br /> APPLICANT'S SIGNATURE: Ql3 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 Rece d <br /> REHS: j'Z�' ��i t�il`�'1 Date °�� / / �r Account out: Date /�_/ <br /> COMMENTS: <br />