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Dale run 1/13/2004 2:37:22PA SAN JO 'JIN COUNTY ENVIRONMENTAL HEA' 'I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1/13/204 <br /> Record Selection Criteria: Facility ID FA0012702 <br /> Make changes/comadlons In RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0009892 New Owner ID <br /> Owner Name TRI VALLEY LINE X INC <br /> Owner DBA TRI VALLEY LINE X <br /> Owner Address 4220 COMMERCIAL DR UNIT 4 <br /> TRACY, CA 95376 <br /> Home Phone 209-599-9279 <br /> Work/Business Phone 209-814-1117 <br /> Mailing Address 4220 COMMERCIAL DR UNIT 4 <br /> TRACY, CA 95376 <br /> Care of BHAKTA,YOGESH <br /> FACILITY FILE INFORMATION <br /> Facility Na lD FA001270 Y LINE X <br /> Facility Name TRI VALLEY LINE X <br /> Location 4220 COMMERCIAL DR UNIT 4 <br /> TRACY, CA 95376 <br /> Phone 209-814-1117 <br /> Mailing Address 4220 COMMERCIAL DR, UNIT#4 <br /> TRACY, CA 95376 <br /> Care of BHAKTA, YOGESH <br /> Location Code 03-TRACY APN:21221005 <br /> BOS District 005-ORNELLAS, LEROY SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0021140 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name TRI VALLEY LINE X (Clyde One) <br /> Account Balance as of 1/13/2004: $0.00 <br /> (Circle One) <br /> Transfer to Activenbactee <br /> Pmgra adElemeM and Description Record ID Employee ID and Name Status New CwneR Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0516603 EE0007380-STEVEN SHIH Active Y N D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0516604 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,me undersigned owner,operator or agent of same,acknowledge that all site,and/or project spank,PHS/EHD hourly charges associated will,Nis <br /> facility or activity will be billed to the parry identified as me OWNER on this form. I also certify mat all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$155.00= Amount Paid Date <br /> Payment T�y��y Cchec�k u_m r Racal b <br /> RENS: <br /> Payment <br /> Date /_�_/ Account out: Date / / /J5/D4. <br /> COMMENTS: <br /> \\Phs-ehsgl-nt\apps\Envisions\Reports\5021.rpt <br />