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Date run 3/11/2016 3:47:20PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 3/11/2016 <br />Record Selection Criteria: Facility ID FA0009209 <br />Program Records to be TRANSFERED: <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE I <br />Amount Paid Date <br />(date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br />Owner ID OW0007209 Case Number: <br />H02052 New Owner ID <br />Owner Name DOUG RAMOS <br />Received by <br />1 / Account out: Date <br />Owner DBA AMERICAN BATTERY CO <br />Il <br />1 1% e l L <br />Owner Address 2245 W CHARTER WAY A <br />I Invoice #: <br />c _� G� l G) ;A 4 _.X +�/ <br />STOCKTON, CA 952061154 <br />Home Phone Not Specified <br />Work/Business Phone 209-464-7348 <br />— <br />Mailing Address 2245 W CHARTER WAY #A <br />STOCKTON, CA 95206-1154 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0009209 10182515 <br />Facility Name AMERICAN BATTERY CO <br />Location 2245 W CHARTER WAY STE A <br />STOCKTON, CA 95206-1120 <br />Phone 209-464-7348 x <br />Mailing Address 2245 W CHARTER WAY #A <br />STOCKTON, CA 95206-1154 <br />�� v <br />Care of Doug Ramos <br />Location Code 01-STOCKTON <br />Alt Phone <br />BOS District 001 - VILLAPUDUA, CARLOS <br />Fax <br />APN 16336017 <br />EMail: <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0016209 <br />New Account ID: <br />Mail Invoices to Account <br />Mail Invoices to: Owner / Facility / Account <br />Account Name AMERICAN BATTERY CO <br />(Circle One) <br />Account Balance as of 3/11/2016: $0.00 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID <br />Employee ID and Name Status New Owner? Delete <br />1921 - HMBP-Reqular-Primary Location PR0519462 <br />EE0009817 - ROBERT LOPEZ Active Y N A C D <br />2220 - SM HW GEN <5 TONS/YR PR0517879 <br />EE0001421 - STACY RIVERA Active Y N A I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511497 <br />EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509209 <br />EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0533652 <br />Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent <br />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 certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: <br />' $25.00 = <br />Amount Paid Date <br />Water System to be TRANSFERED: <br />Amount Paid Date <br />Payment Type <br />EHD Staff: <br />Check Number <br />e- 2_ Date _2_ i / <br />Received by <br />1 / Account out: Date <br />COMMENTS: <br />1n /� <br />YV \ Z ✓ t i� <br />Il <br />1 1% e l L <br /><2 � (O L-� <br />I Invoice #: <br />c _� G� l G) ;A 4 _.X +�/ <br />— <br />