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Date run : 2/25/00 4:19:39PM SAt -,oAQU1N COUNTY PUBLIC HEALTH SEI '-.'ZS Report #: 0002 <br /> Run by LBROWN — Facility Information as of 2/25/00 Page #: 1 <br /> Record Selection Criteria: Facility ID FA0012225 <br /> l <br /> Record ID <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION,CHANGE (date) <br /> OWNERSHIP"CHANGE (date) <br /> OWNER FILE INFORMATION / <br /> Owner ID: OW0004890 New <br /> Owner ID <br /> Owner Name: POMBO, ERNEST J <br /> Owner DBA: ERNEST J. POMBO <br /> Owner Address: 24100 S LAMMERS ROAD <br /> TRACY, CA 95376- <br /> Home Phone: Not Specified <br /> Work/Bussness Phone: Not Specified <br /> Mailing Address: PO BOX 805 <br /> TRACY, CA 95376- <br /> Care of: ERNEST J POMBO <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0012225 <br /> Facility Name: POMBO REAL ESTATE rl-t M <br /> Location: 1755 W 11TH ST <br /> TRACY, CA 95376 y, t�.i D O��G'7Phone: 209-835-4949 /( T'( / <br /> Mailing Address: PO BOX 805 <br /> TRACY, CA 95376- <br /> Care of: ERNEST J POMBO <br /> Location Code: 03 -TRACY APN; <br /> BOS District: SIC Code., <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0019735 New Account ID:: <br /> Mail Invoices to: Account Mail Invoices to: Owner/ Facility/Account <br /> Account Name: EARTH SYSTEMS CONSULTANTS (Circle One) <br /> Account Balance as of 2/25/00: $0.00 <br /> (Circle One) <br /> UST(s) Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status Linked New Owner? <br /> 2950-ENVIRON ASSESS PR0515574 EE0000684-INFURNA 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 <br /> project specific,PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this <br /> form. I also certify that all operations will be performed in accordance with all applicable Ord inace Codes and/or Standards and State and/or Federal <br /> Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$0.00= Amount Paid Date <br /> Water System to be TRANSFERED: *$150.00= Amount Paid Date <br /> Payment Type Check Number Receipt Number Received by <br /> REHS: Date / / Account out: Date <br /> 1.0.0.89.00 <br />