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wlea,n 3/21/2012 3:07:19PR SAN JQUIN COUNTY ENVIRONMENTAL HE/ "H DEPARTMENT Report OW21 <br /> Run M � <br /> RPagel <br /> Facility Information as of 3/21/202 <br /> Record Selection Catena: Facility ID FA0010953 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP <br /> <br /> Owner ID OW0008953 Case Number: H09961 New Owner ID <br /> Owner Name TRACY MOT R PORP <br /> Owner DBA <br /> Owner Address 1129W 11TH ST <br /> Home Phone Not Specified <br /> Work/Business Phone pgq_$ g <br /> Mailing Address 1129 W 11 TH ST <br /> TRACY, CA 95376 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010953 <br /> Facility Name TRACY WS F LSF r` ^ nl p <br /> Location 1129 W 11TH ST <br /> TRACY, CA 95376 <br /> Phone 209-836-662. - 9 LSa <br /> Mailing Address 1129 W 11TH ST <br /> TRACY, CA 95376 <br /> Care of EtAb43ta,AAPci AM��� ( '57r) :M <br /> Location Code 03-TRACY Alt�hone— <br /> BOS District 005-ORNELLAS, LEROY Fax 2D - O 5 <br /> APN Entail: ttn f.. KfJ- -pr•7, <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017953 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name TRACY MOTOR CORP (Circie One) <br /> Account Balance as of 3/21/2012: $0.00 <br /> (circle One) <br /> Program/Element and Description Record ID Empbyee ID and Name Stanrs Transfer to Active/Inacive <br /> New Owner! Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513241 EEOOOOOOO-HAZ MAT SJC OES Inactive Y N A I D <br /> 23 IFIED�jP•py,O(r7y �,�/yy"'STATE SU ARnP�2R0510953 EE0000000-HAZ SJ Inactive Y N A I D <br /> BILL andl.1PLMNL'EA I(I�Oy6`tDGEMENT. I, de�islg ce a or u ofr e, a an or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billetl to the rty itlenefied as the OWNER on this form. also certgy that all ffperations will be need in accordance with all applicable Ordinate Codes and/or Standards and <br /> State andlor Federal L. <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 Recei <br /> REHS: Date / 7i Account out: _ Date / 1 '-7 <br /> COMMENTS: e,& POW- <br /> OVK <br /> \\eh-en v\envision\reports\5021.rpt <br />