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Date run 7/17/2003 9:28:31AN SAN JC ' 7UIN COUNTY ENVIRONMENTAL HE.-" - —H DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 7/17/2u,3 <br />Record Selection Criteria: Facility ID FA0013644 <br />OWNER FILE INFORMATION <br />Owner ID OW0010757 <br />Owner Name <br />Owner DBA <br />Owner Address <br />Home Phone Not Specified <br />Work/Business Phone 209-365-6747 <br />Mailing Address 820 BECKMAN RD #3 <br />LODI, CA 952403147 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0013644 <br />Facility Name <br />GASOLINE ALLEY <br />Location <br />720 E LODI AVE <br />(Circle One) <br />LODI, CA 95240 <br />Phone <br />209-365-6747 <br />Mailing Address 820 BECKMAN RD #3 <br />LODI, CA 952403147 <br />Care of <br />Location Code <br />BOS District <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0022800 <br />Mail Invoices to Facility <br />Account Name GASOLINE ALLEY <br />Account Balance as of 7/17/2003: $0.00 <br />Make changes/corrections in RED ink or pencil. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANG <br />New Owner ID : <br />I-1 o <br />LS to a A---64 . D o m <br />(, C- UL -7-(D <br />D3 R D <br />2- <br />20 12 —1113 1 <br />0k -r (LSI Au-? <br />3t. -7 -If -70 <br />A Z7a /11A -t r4e-?0 <br />a -p e Lo b I A <br />Vc- <br />Lzbtt CA � 4� <br />APN: <br />SIC Code:9900 <br />New Account ID: <br />Mail Invoices to: Owner Facility / Account <br />ne) <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 <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 />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 />\\Phs-ehsq I -n t\apps\Envisions\Reports\5021. rpt <br />* $20.00 = Amount Paid <br />* $155.00 = Amount Paid <br />Date <br />Date <br />Date / ! <br />Received by <br />Date / / Account out: 2.� Date 7 / I7 /0.3 <br />(Circle One) <br />Transfer to <br />Active/Inactve <br />Program/Element and Description Record ID <br />Employee ID and Name <br />Status <br />New Owner? <br />Delete <br />2220 - SM HW GEN <5 TONSNR PR0517990 <br />EE0008389 - DENNIS CATANYAG <br />Inactive <br />Y <br />N <br />A <br />I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0517991 <br />EE0000000 - HAZ MAT SJC OES <br />Inactive <br />Y <br />N <br />A <br />I D <br />2244 - PACT TRANSFER RECORD - OES PRO521048 <br />EE0000000 - HAZ MAT SJC OES <br />Inactive <br />Y <br />N <br />A <br />I D <br />2399 - UNIFIED PROGRAM FAC STATE SERVICE FPR0517992 <br />EE0000000 - HAZ MAT SJC OES <br />Inactive <br />Y <br />N <br />A <br />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 <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 />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 />\\Phs-ehsq I -n t\apps\Envisions\Reports\5021. rpt <br />* $20.00 = Amount Paid <br />* $155.00 = Amount Paid <br />Date <br />Date <br />Date / ! <br />Received by <br />Date / / Account out: 2.� Date 7 / I7 /0.3 <br />