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Date run 1b 5/7/2014 4:18:33PM SAN JO, 1IN COUNTY ENVIRONMENTAL HEAT DEPARTMENT Report#5021 <br />Xun by Pagel <br />Facility Information as of 5/7/2014 <br />Record Selection Criteria: Facility ID FA0022309 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0018592 <br />Owner Name <br />SANTIAGO, JORGE <br />Owner DBA <br />4113 N WEST LN A <br />Owner Address <br />4444 FEATHER RIVER DR <br />Phone <br />STOCKTON, CA 95219 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-938-9672 <br />Mailing Address <br />99 - UNINCORPORATED P <br />Care of <br />SANTIAGO, JORGE <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0022309 <br />Facility Name <br />TOYO OF STOCKTON <br />Location <br />4113 N WEST LN A <br />STOCKTON, CA 95204 <br />Phone <br />209-938-9672 <br />Mailing Address <br />Care of <br />SANTIAGO, JORGE <br />Location Code <br />99 - UNINCORPORATED P <br />Bos District <br />002 - RUHSTALLER, LARRY <br />APN <br />11531022 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name JORGE SANTIAGO <br />Title <br />Day Phone 209-938-9672 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0040729 <br />Mail Invoices to Facility <br />Account Name TOYO OF STOCKTON <br />Account Balance as of 5/7/2014: $478.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />1 SSN /Fed Tax ID <br />New Owner ID : <br />4 11 3 N• W EST L N A <br />S T'DGIc.Tb n , C -4� 9's zoo <br />114 I.13 N \,JEST LN A <br />57-QC-k.TDN) Gk ci 510 q <br />Alt Phone <br />Fax <br />EMail : <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1920 - HMBP-Common Materials PR0538842 EE0009817 - ROBERT LOPEZ Active Y N A I D <br />2220 - SM HW GEN <5 TONS/YR PR0538841 EE0004636 - GARRETT BACKUS Active Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator 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 certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State andlor <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: <br />COMMENTS: <br />* $25.00 = <br />Date <br />Date <br />Amount Paid Date -/-/ <br />_ Amount Paid Date <br />Received by <br />Account out: Date <br />