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Date run 8/30/2004 8:41:51AK SAN J*UIN COUNTY ENVIRONMENTAL HEA9I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/30/2004 <br /> Record Selection Criteria: Facility ID FA0015632 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0012580 New Owner ID <br /> Owner Name DOLE, MARVIN <br /> Owner DBA MID-VALLEY DEVELOPMENT LLC <br /> Owner Address 7109 HILLCREST DR <br /> MODESTO, CA 95356 <br /> Home Phone 209-545-3704 <br /> Work/Business Phone Not Specified <br /> Mailing Address 7109 HILLCREST DR <br /> MODESTO, CA 95356 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015632 <br /> Facility Name NORTRAX <br /> Location 8621 S EL DORADO ST <br /> FRENCH CAMP, CA 95231 <br /> Phone 209-983-8122 <br /> Mailing Address 8621 S EL DORADO ST <br /> FRENCH CAMP, CA 95231 <br /> Care of MID-VALLEY DEVELOPMENT LLC <br /> Location Code 99 - UNINCORPORATED AREA APN:19320005 <br /> BOS District 001 - GUTIERREZ, STEVE SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0027014 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name ERM (Circle One) <br /> Account Balance as of 8/30/2004: $-279.00 <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 /> 2950-ENVIRON ASSESS PR0523156 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 System to be TRANSFERED: '$155.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / ! Account out: Date <br /> COMMENTS: <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />