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Date run 10/23/2008 10:22:26/ SAN JUIN COUNTY ENVIRONMENTAL HE H DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 10/23/ 8 <br />Record Selection Criteria: Facility ID FA0011023 <br />Make changes/corrections in RED ink or pencil. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION SSN/Fed Tax ID <br />Owner ID OW0007393 Case Number: H03711 New Owner ID : <br />Owner Name - CU4N-�r+ff '_� ��Li•L11 �. <br />Owner DBA 7� <br />Owner Address <br />ST $AD <br />Home Phone Not Specified /v j� _ <br />Work/Business Phone 209-944-5821 <br />Mailing Address PO BOX 6463 <br />STOCKTON, CA 95206 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0011023 <br />Facility Name <br />INTERSTATE TRUCK CTR - COLLISION DI <br />Location <br />641 S HARRISON ST <br />STOCKTON, CA 95206 <br />Phone <br />209-467-3561 <br />Mailing Address <br />PO BOX 6463 <br />STOCKTON, CA 95206 <br />Care of <br />Location Code <br />BOIS District <br />APN <br />147-040-47 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0018023 <br />Mail Invoices to Facility <br />Account Name INTERSTATE TRUCK CTR - COLLISION DI <br />Account Balance as of 10/23/2008: $0.00 <br />Program/Element and Description Record ID Employee ID and Name <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Status New Owner! Delete <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513311 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />2227 - GEN 5<25 TONS PERMIT PRO514497 EE0008317 - RAYMOND VON FLUE Active Y N A I D <br />2244 - PACT TRANSFER RECORD - OES PRO520616 EE0000000 - HAZ MAT SJC OES Active Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARPRO511023 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: ],the undersigned owner, operator or agent of same, acknowledge that all site, arM/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. y ^ ^& - l _ C <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: ' $20.00 = Amount Paid <br />Water System to be TRANSFERED: " $372.00 = Amount Paid <br />Date <br />Date / <br />Date <br />Payment 7n4pe Check Number Received by <br />RENS: Trow T4& Date/22/� Account out: �� Date / D / - 08 <br />COMMENTS: <br />\\phs-ehsql-nt\apps\envisions\reports\5021. rpt <br />