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T Report#5021 <br /> Date run 8/8/2003 2:48:25PM SAN Jo -aN COUNTY ENVIRONMENTAL HEA' t DEPARTMENT Pagel <br /> Run by �,. <br /> Facility Information as of 8/8/200 <br /> Record Selection Criteria: Facility ID FA0012157 <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 Owner ID <br /> Owner Name POMBO, ERNEST J JR <br /> Owner DBA POMBO REAL ESTATE <br /> Owner Address 24100 S LAMMERS ROAD <br /> TRACY, CA 95376 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 805 <br /> TRACY, CA 95376 <br /> Care of ERNEST J POMBO JR <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012157 <br /> Facility Name POMBO REAL ESTATE <br /> Location 1755 W 11TH ST <br /> TRACY, CA 95376 <br /> Phone 209-835-4949 <br /> Mailing Address PO BOX 805 <br /> TRACY, CA 95378 <br /> Care of ERNEST J POMBO JR <br /> Location Code 03-TRACY APN: <br /> BOS District 005-ORNELLAS, LEROY SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0019502 New Account ID: <br /> Mail Invoices to Account / Mail Invoices to: Owner / Facility / Account <br /> Account Name CHEVRON ENVIRONMENTAL MGMT CO'O'L (Circle One) <br /> Account Balance as of 8/8/2003: $0.00a'�� <br /> (-Circle One) <br /> Transfer to <br /> Active/Inactve <br /> Program/Element and Description tSfC Record IDC Employee ID and Name 0#—' Status New Owner? Delete <br /> 2960-RWQCB CLEAN UP SITE(SLIC) PR0515454 EE0000684f�MICHAEL INFURNALtor <br /> Inactive Y N I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site, project specific,PHS/EHD hourly charges associated with this <br /> facility 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be TRANS/FERED: *$155.00= Amount Paid �Date <br /> Payment Type / Check Number Received by <br /> RENS: Date Account out: �_ A?14,,L—Date <br /> COMMENTS: <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rptG+� C <br /> f '7q({ <br />