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Date run 3/11/2009 8:43:53AN SAN J#IN COUNTY ENVIRONMENTAL HEA- i DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/11/2uuy <br /> Record Selection Criteria: Facility ID FA0003605 <br /> L-unchanges/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> MSR 1 1 209 �.— OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner 1D OW0001009NVIRONMENT HEALTH New Owner x : <br /> Owner Name CALTRANS/ BI�F—�ICES <br /> Owner DBA DEPARTMENT OF TRANSPORTATION <br /> Owner Address 1976 E CHARTER WAY <br /> STOCKTON, CA 95205 <br /> Home Phone 209-483-3088 <br /> Work/Business Phone 209-948-7556 <br /> Mailing Address PO BOX 2048 <br /> STOCKTON, CA 95201 <br /> Care of CHRIS MARTIN, HAZ MAT MGR <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0003605 <br /> Facility Name TRACY MAINTENANCE STATION <br /> Location 2040 KROHN RD <br /> TRACY, CA 95377 <br /> Phone 209-835-6779 <br /> Mailing Address PO BOX 2048 <br /> STOCKTON, CA 95201 <br /> Care of CHRIS MARTIN, HAZ MAT MGR Odri <br /> Location Code 03 - TRACY Alt Phone <br /> BOS District 005 - ORNELLAS, LEROY Fax <br /> APN 24003004 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name ROGER MORAN <br /> Title SUPERVISOR <br /> Day Phone 209-835-6779 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003183 New Account ID <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name TRACY MAINTENANCE STATION (Circle One) <br /> Account Balance as of 3/11/2009: $0.00 <br /> (Circle One) <br /> Pro ram/Element and Description Transfer to Active/Inactve <br /> Program/Element P Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0514041 EE0005642-MICHELLE HENRY Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0512091 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0519879 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0231544 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPRO509803 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2831 -AST FAC >/= 1,320-<10 K GAL CUMULATI\PR0528305 EE0005642-MICHELLE HENRY Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/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. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: *$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: >zj �?j Date Sl l Il C'j Account out: �� Date�_/ <br /> COMMENTS: <br /> \\e h-env\envision\reports\5021.rpt <br />