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Date run 12/13/2013 3:39:05P SAN JO/ �♦(COUNTY ENVIRONMENTAL HEADPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/23/2013 <br /> Record Selection Criteria: Facility ID FA0019169 <br /> Make changestcorrections in RED ink. Z 3 <br /> INFORMATION CHANGE(date) L <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN 1 Fed Tax ID <br /> Owner ID OW0007811 Case Number: H05501 New Owner ID <br /> Owner Name TRACY, CITY OF <br /> Owner DBA CITY OF TRACY WATER TREATMENT <br /> Owner Address 3900 HOLLY DR <br /> TRACY, CA 95304 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 3900 HOLLY DR <br /> TRACY, CA 95304 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0019169 10187079 <br /> Facility Name WELL#7 WATER TREATMENT <br /> Location 2100 TRACY BLVD Vn <br /> TRACY, CA 95376 <br /> PhoneQ�QQQ�} (� <br /> Mailing Address 3900 HOLLY DR <br /> TRACY, CA 95304 <br /> Care of CITY OF TRACY <br /> Location Code ii Alt Phone <br /> BOS District W5 Fax <br /> APN 23 05] EMail: /341 C Ar GrL Cf f4(,)'L1 - JS <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name n A-V I b CA r- <br /> Title W ArG �`U ULi 1d1% (JIOAVL <br /> Day Phone p — 112 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0034121 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name WELL#7 WATER TREATMENT (Circle One) <br /> Account Balance as of 12/23/2013: $0.00 <br /> (Circle One) <br /> Transfer to Activellnadve <br /> ProgramlElement and Description Record ID Employee ID and Name ` '�, `` Status New Dwner? Delete <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO528401 EE0009488-J�1G Active,l Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHS/El 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 and/or Standards and State andlor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date / 1 <br /> Payment Type Check Number Receive <br /> RENS: n "T���LA - _ Date 1-l1�Pl ( 3 Account out: Date !� <br /> COMMENTS: <br /> no P 7, ILI <br /> PRos��a�� <br />