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Date run 8/26/2003 1:43:38PN SAN QUIN COUNTY ENVIRONMENTAL HH DEPARTMENT Report#5021 <br /> Pagel <br /> Run by Facility Information as of 8/26/2003 <br /> Record Selection Criteria: Facility ID FA0007342 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0006051 New Owner ID <br /> Owner Name CHEVRON ENVIRONMENTAL MGMT CO <br /> Owner DBA <br /> Owner Address YON RD RM K20722-- <br /> SAN RAMON, CA 945830712 <br /> Home Phone 925-842-5216 <br /> Work/Business Phone Not Spee#ieeF-- <br /> Mailing Address PO BOX 6012 <br /> SAN RAMON, CA 945830712 <br /> Care of PENNY T FOTTRELL <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0007342 / �� <br /> Facility Name CHEVRON PIPELINE/RENOWN PROPERTY W/ <br /> Location 990 BEECHNUT AVE <br /> TRACY, CA 95376 <br /> Phone <br /> Mailing Address 6001 BOLLINCz 2 111:'� ( '., <br /> SAN RAMON, CA 94583 —6-11 'L_ <br /> Care of PENNY T FOTTRELL 9025- � - <br /> Location Code 03 -TRACY APN: <br /> BOS District 005-ORNELLAS, LEROY SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0010950 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CHEVRON ENVIRONMENTAL MGMT CO (Circle One) <br /> Account Balance as of 8/26/2003: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> New Owner? Delete <br /> Program/Element and Description Record ID Employee ID and Name Status <br /> 2960-RWOCB CLEAN UP SITE(SLIC) PR0506314 EE0000684-MICHAEL 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 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 Systemtb be RANSFERED: *$155.00= Amount Paid Date <br /> Payment Typ� Check Number d by ._ <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rpt <br />