Laserfiche WebLink
ER=rd <br /> 5/18/2015 10:45:17AI ;rF;AUO2;07[ui <br /> AQUIN C ;Facility <br /> ENVIRONMENTAL HEALTH DEPARTMENT Report k50Y1 <br /> Information as of 5/18/2015 Pagel <br /> ection Critetle: Fedliry ID <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: 1 SSN/Fed Tax ID : <br /> Owner ID OW0017010 New Owner ID <br /> Owner Name Diesel Direct InC <br /> Owner DBA DIESEL DIRECT WEST <br /> Owner Address 4412 HARLIN DR <br /> SACRAMENTO, CA 95826 <br /> Home Phone Not Specified <br /> Work/Business Phone 888-900-7787 <br /> Mailing Address 74 Maple St <br /> Stoughton, MA 02072 <br /> Care of TIM JOHNSON <br /> FACILITY FILE INFORMATION <br /> Facility 10/CERS ID FA0020701 10453072 <br /> Facility Name Diesel Direct West <br /> Location 3734 Imperial Way Ste E <br /> Stockton, CA 95215 <br /> Phone 916-857-1000 x <br /> Mailing Address 3734 Imperial Way Ste E <br /> Stockton, CA 95215 <br /> Care of Tim Johnson <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 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 AR0037118 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Diesel Direct West (Circle One) <br /> Account Balance as of 5/18/2015: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> ProgranvElement and Descrption Record ID Employee to and Name Status New Owner! Delete <br /> 1921 -HMBP-Regular-Primary Location PR0535942 EE0009817-ROBERT LOPEZ Active Y N AD <br /> 2220-SM HW GEN<5 TONS/YR PR0538608 EE0001421 -STACY RIVERA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0535958 InactivE Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party Identified as Ne OWNER on this form. I also certify Mat all openetions will be performed in accordance with all applicable Ordinance Codes andor Standards and State ands <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: 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 Received b <br /> EHD Staff: ' -----_ Date � _z/ ` Account out: > Date <br /> COMMENTS' <br /> (� �( • Invoice#: <br /> e— <br />