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Date run 7!612011 4:00:36PM SAN df '7UIN COUNTY ENVIRONMENTAL EIEC -5 DEPARTMENT Report 115021 <br /> Run by Pagel <br /> Facility.Information as of 7/6120 <br /> Record Selection Criteria: Facility ID FA0018816 <br /> i Make changeslcorrections In RED ink. <br /> �( INFORMATION CHANGE(date) <br /> 1 OWNERSHEP_CHANGE(date) - <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> ��o loo <br /> Owner ID OW0015477 New Owner ID <br /> Owner Name QUALITY LIFT TRUCK INC S <br /> A Owner DBA 01; t✓ <br /> Owner Address 4884 FRONTIER WAY STE-A <br /> STOCKTON, CA 952ECEIVED <br /> Home Phone 209-465-8987 , <br /> Work/Business Phone Not Specified ,JAN 2-6 2012 <br /> Mailing Address PO BOX 31922 <br /> STOCKTON, CA 9521MN JOAQUIN COUNTY <br /> Care of QUALITY LIFT TRM(Ei MERGENCY SERVICES <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0018816 <br /> Facility Name QUALITY LIFT TRUCK INC (1 O M!Elel tIV E-NT <br /> Location 4884 FRONTIER WAY STE_ A <br /> STOCKTON, CA 95215 <br /> Phone 209-465-8987 <br /> Mailing Address PO BOX 31922 -10 t O Q <br /> STOCKTON, CA 95213 (14 <br /> Care of NA Ok2fllll, <br />` Location Code Alt Phone <br /> BOS District Fax. <br /> APN 17926043 EMail:, <br /> I` EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact'Name GARY BICKNELL <br /> Title OWNER <br /> Day Phone 209-465-8987 CJ -0ro <br /> 00 <br /> Night Phone 209-992-7036 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> l Account ID AR0033424 New Account.ID: ; <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name QUALITY LIFT TRUCK INC (Circle One) <br /> I <br /> Account Balance as of 71612011: $0.00 <br /> (Circle One) <br /> Transfer to Active/lnactve <br /> ProgramMement and Description -Record ID Employee ID and Name Status r? Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO527759 EE0001421 -STACY RIVER_A Active N- A<02YD <br />'I 2244-PACT TRANSFER RECORD-OES PRO528769 ActiveY N A I D <br /> 4740,1-WASTE TIRE SITE-EXEMPT PRO535788 EE0007376:AMANDA BOERTIEN Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPRO532601 Active Y N' A I D <br /> I BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner•operator or agent of same,acknowledge that all site,and/or project specific,PHSIEHD 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 /> i . <br /> APPLICANT'S SIGNATURE: Date ! ! <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / 1 <br /> Water System to be TRANSFERED• Amount Paid Date I / <br /> Payment Type ��&c� Number Reeeiv <br /> Date Account out: Date. l1 <br /> i COMMENTS: <br />'I 11eh-env\envision\reportsl502l.rpt <br />