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Date run 2/28/2003 2:16:10PN SAN JOA UIN COUNTY ENVIRONMENTAL HE I DEPARTMENT Report#5021 <br /> Runby Pagel <br /> Facility Information as of 2/28/2 <br /> Record Selection Criteria: Facility ID FA0013716 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0001275 New Owner ID <br /> Owner Name SMITH, ANDREW <br /> Owner DBA HERMAN & HELEN'S MARINA <br /> Owner Address 15135 W EIGHT MILE RD <br /> STOCKTON, CA 95209 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-951-4634 <br /> Mailing Address 15135 W EIGHT MILE VENICE ISLAND FEF <br /> STOCKTON, CA 95219 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013716 <br /> Facility Name HERMAN & HELEN'S MARINA <br /> Location 15135 EIGHT MILE RD <br /> STOCKTON, CA 95219 <br /> Phone 209-951-6505 <br /> Mailing Address 15135 EIGHT MILE RD <br /> STOCKTON, CA 95219 <br /> Care of ANDREW SMITH <br /> Location Code 01 -STOCKTON APN: <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR002296Z New Accou D: <br /> Mail Invoices ccount Mail Invoices to: er / Facility / Account <br /> Account Name ADVANeEO 6EOENVIR6NAAE#T�n,�l v (Circle one> <br /> Account Balance as of 2/28/200 . 801.00AY �� —6 3 7(p,�. <br /> T (Circle One) <br /> Transfer to <br /> Active/InacNe <br /> Program/Element and Description Record ID Employee ID and Na Status NeN'Comer? Delete <br /> 2960-RWQCB CLEAN UP SITE(SLIC) PRO518132 EE0000 -MARGARET LAGORIO tive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator w agent of sit adgathatall site,and/or project specific,PHS/EHD hound charges associated with this <br /> facility or activity will be billed to the party Identifred 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: Date / / <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date / ! <br /> Water System to be TRANSFERED: "$155.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: '9�� Date <br /> COMMENTS: (� D <br /> X 103 T�C,Y c � ,�6, I�ILu4-13L� /�f4' —r7 <br /> yes m <br /> \\Phs-ehsql-nt\apps\Envisions\Repoftk502l.rpt <br />