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Date run 3/17/2014 4:00:47PA SAN JOWIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Pagel <br /> Run by Facility Information as of 3/17/2014 <br /> Record Selection Criteria. Facility ID FA0021428 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) y- <br /> OWNER FILE INFORMATION SSNI Fed Tax ID <br /> Owner ID OW0017621 New Owner ID <br /> Owner NameG'rp T <br /> Owner DBA _ �G94N e�,r AIV R-&H <br /> Owner Address 363E <br /> /.4 45^J-7.7 <br /> n <br /> Home Phone Not Specified <br /> Work/Business Phone 46-9 " qm�51 9 <br /> Mailing Address 8966 GQMGAS:F <br /> LI)(FRP (;R9 re OAFF1 �/+cc 7�7 <br /> Care of w rra �4 sd/ f v <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021428 10187899 <br /> Facility Name ` GTD-:r' <br /> Location 25201 S SCHULTE RD 1214-B6– <br /> TRACY, CA 95377 <br /> Phone q26 " XQ O9 32 — 636 <br /> Mailing Address 8855-GOMGAST Z`�� I �� /'� 2,d <br /> 1 t naeRE G 9 66" l'�-- GA 14537:2 <br /> Care of T <br /> Location Code 03-TRACY Alt Phone <br /> BOS District 005- ELLIOTT, BOB Fax <br /> APN 20944028 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 AR0038793 New Account to: <br /> Mail Invoices to: Owner / Facility / Account <br /> Mail Invoices to Owner <br /> (circle One) <br /> Account Name COMCAST CORPORATION <br /> Account Balance as of 3/17/2014: $32fr90— (Circle One) <br /> Transferlo Activellnachve <br /> Program/Element and Description <br /> Record ID Employee ID and Name Status Owned Delete <br /> 1921 -HMBP-Regular-Primary Location PR0537312 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the parry identified as the OWNER on this form. 1 also certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and Slate anclor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: 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 Receive 141 <br /> REHS: Date 73 _ L Account out: Date_/ <br /> COMMENTS: <br />