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Date run 2/20/2013 1;1 12:49AI SAN JUIN COUNTY ENVIRONMENTAL HEAV DEPARTMENT Report#5021 <br /> Run byPagel <br /> Facility Information as of 2/20/2013 <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 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 /> Owner Address 600 E SCHULTE RD <br /> TRACY, CA 95376 <br /> Home Phone Not Specified <br /> Work/BusinessPhone 209-835-2930 <br /> Mailing Address PO BOX 327 <br /> 0SCarTRACY, CA 95378 g5371, �r 105— <br /> Care <br /> e of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0007979 <br /> Facility Name TRACY PUBLIC CEMETERY <br /> Location 600 E SCHULTE RD <br /> TRACY, CA 95376 <br /> Phone 209-835-2930 x0 <br /> Mailing Address PO BOX 327 J�fJ � �!+}IULT� <br /> TRACY, CA 95378' Q5376 —Shf 5 <br /> Care of <br /> Location Code 03-TRACY Alt Phone <br /> BOS District 005-ORNELLAS, LEROY 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: Owner I Facility / Account <br /> Mail Invoices to Owner <br /> Circle One) <br /> Account Name TRACY PUBLIC CEMETERY DIST <br /> Account Balance as of 2/20/2013: $135.00 (Circle one) <br /> Transfer to Activellnactve <br /> P MElemenl and Desulpgon <br /> Record ID Employee ID and Name Status New Owner? Delete <br /> 1920 HMBP-Common Materials PR0520363 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> -HAZ MAT BUSINESS PLAN AUTHORIZATIOPPRO517853 EE0000000-HAZ MAT SJC IDES 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 SURCHAR(PRO517854 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0533993 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I.the undersigned owner,operator or agent of same,acknowledge that all site,andror project speck,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party senttried as the OWNER on this form I also certify Nat all operations will be performed in accordance wBh all applicable Ordinance Codes andror Standards and Stale 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 b <br /> REHS: Date_/ /_ Account out: Date <br /> COMMENTS: <br />