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Date run 3/31/2017 4:23:50PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 3/31/2017 <br />Record Selection Criteria: Facility ID FA0020347 <br />OWNER FILE INFORMATION Number of facilities for this owner: 2 <br />Owner ID OW0016705 <br />Owner Name HD SUPPLY CONSTRUCTION SUPPLY, L <br />Owner DBA <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID : <br />Owner Address <br />3100 CUMBERLAND BLVD 1226 <br />ATLANTA, GA 30339 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />770-852-9300 <br />Mailing Address <br />3100 CUMBERLAND BLVD MS -1226 <br />sfer to <br />ATLANTA, GA 30339 <br />Care of <br />Record ID <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0020347 10187579 <br />Facility Name <br />HD SUPPLY CONSTRUCTION SUPPLY WC( <br />Location <br />1166 S Wilson Way <br />Active <br />Stockton, CA 95205 <br />Phone <br />209-944-9541 x <br />Mailing Address <br />6250 Brook Hollow Pkwy, Suite 100 <br />Active; <br />Norcross, GA 30071 <br />Care of <br />HD Supply Construction Supply, Ltd (WCO23) <br />Location Code Alt Phone <br />BOS District 001 - VILLAPUDUA, CARLOS Fax <br />APN 15512012 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 AR0036334 <br />Mail Invoices to Account <br />Account Name Kevin Pierce <br />Account Balance as of 3/31/2017: $0.00 <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <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 andor <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />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 7 <br />EHD Staff: R W -N —c> --Date Account out: Date <br />COMMENTS: Invoice #: U / <br />��c,�,Mte�. PRo�35�31. A� pei GC R� 5�5r~�r�l. 3J �I�e► -- ? <br />Lk /1—�. �J�r <br />(Circle One) <br />sfer to <br />Active/Inactve <br />Program/Element and Description <br />Record ID <br />Employee ID and Name <br />Status <br />New ner? <br />Delete <br />1921 - HMBP-Regular-Primary Location <br />PR0535232 <br />EE0009817 - ROBERT LOP Z <br />Active <br />Y N <br />A I D <br />2220 - SM HW GEN <5 TONS/YR <br />PR0536884 <br />EE0000023 - PAULINE M N`GRAI <br />Active; <br />, N <br />A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG <br />PR0535268 <br />-Inactive <br />Y N <br />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 andor <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />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 7 <br />EHD Staff: R W -N —c> --Date Account out: Date <br />COMMENTS: Invoice #: U / <br />��c,�,Mte�. PRo�35�31. A� pei GC R� 5�5r~�r�l. 3J �I�e► -- ? <br />Lk /1—�. �J�r <br />