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Date run 12/28/2017 2:12:02P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/28/2017 <br /> Record Selection Criteria: Facility ID FA0007979 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0006594 New Owner ID <br /> Owner Name TRACY PUBLIC CEMETERY DIST <br /> Owner DBA TRACY PUBLIC CEMETERY DISTRICT <br /> OwnerAddress 501 E SCHULTE RD <br /> TRACY, CA 95376-8105 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-835-2930 <br /> Mailing Address 501 E. SCHULTE RD <br /> TRACY, CA 95376 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0007979 10182323 <br /> Facility Name TRACY PUBLIC CEMETERY <br /> Location 501 E SCHULTE RD <br /> TRACY, CA 95376 <br /> Phone 209-835-2930 x0 <br /> Mailing Address 501 E.SCHULTE RD <br /> TRACY, CA 95376 <br /> care of TRACY PUBLIC CEMETERY DISTRICT <br /> Location Code 03 -TRACY Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN 23511005 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 AR0014814 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name TRACY PUBLIC CEMETERY (cbcleOne) <br /> Account Balance as of 12/28/2017: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> ommon Material M <br /> I NNW <br /> 2224-HAZ MAT BUSINESS P I N PR0517853 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0508180 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO517854 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO533993 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: L the undersigned owner,operator or agent of same,acknowledge that all site,anclor project specific,PHSfEHD 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 anclor Standards and State 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 Received by <br /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: Invoice#: <br />