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Daterun -4212012013 4:04:29FReport#5021 <br /> SAN JOv COUNTY ENVIRONMENTAL HEALEPARTMENT Pagel <br /> R"ry Facility Information as of 12/20/2013 <br /> Record Selection Criteria: Facility ID FA0019167 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) J <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/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 FA0019167 10187075 <br /> Facility Name WELL#5 WATER TREATMENT <br /> Location 1050 TWELFTH ST Q " <br /> TRACY, CA 95376 <br /> Phone e0N 001 <br /> Mailing Address 3900 HOLLY DR <br /> TRACY, CA 95304 <br /> Care of CITY OF TRACY <br /> Location Code 03 Alt Phone <br /> BOS District 005 Fax <br /> APN 237-2470 -7 EMail: A V.e, C A(+ Cir G -C A.0 <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION L <br /> Contact Name Atj 11�`TQ <br /> Title a'L r0DU <br /> Day Phone ZO <br /> Night Phone r705) 4031 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0034119 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name WELL#5 WATER TREATMENT (Circle One) <br /> Account Balance as of 12/20/2013: $0.00 <br /> (Circle One) <br /> Transfer to Active/lnactve <br /> Program/Element and Description Record tD Employee ID and Name &&JL �` Status New Owner? Delete <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO528398 EE0009488 r Active,i Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on thts 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 /> APPLICANT'S SIGNATURE: Date / 1 <br /> Program Records to be TRANSFERED: $25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date 1 ! <br /> Payment Type Check Number Receiv <br /> REHS: yy-r-� r-4 V __ Date�_! '27 113 Account out: Date <br /> COMMENT <br /> o Pr 101 X icsj lv�—r <br />