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Date run 3/9/2005 2:01:38PM SAN JO.#IN COUNTY ENVIRONMENTAL HEA If DEPARTMENT Report#5021 <br /> Run by 4006 Pagel <br /> Facility Information as of 3/9/2005 <br /> Record Selection Criteria: Facility ID FA0015410 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0002290 New Owner ID <br /> Owner Name SPATAFORE, CHARLES <br /> Owner DBA <br /> Owner Address 4720 S LAMMERS RD <br /> TRACY, CA 95377 <br /> Home Phone 209-835-5804 <br /> Work/Business Phone Not Specified <br /> Mailing Address 4720 S LAMMERS RD <br /> TRACY, CA 95377 <br /> Care of CHARLES SPATAFORE <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0015410 <br /> Facility Name CHARLIE SPATAFORE PROPERTY <br /> Location 23577 MOUNTAIN HOUSE PKWY Ai-Aeo ,-4 f <br /> TRACY, CA 953049600 <br /> Phone — In N {/_ t✓i�-.e/ S LLC/ <br /> Mailing Address 23577 MOUNTAIN HOUSE PKWY X100 N o P rte . tc LoZ <br /> TRACY, CA 953049600 <br /> Care of CHARLES SPATAFORE <br /> Location Code 99-UNINCORPORATED AREA APN 20908021 <br /> BOS District 005-ORNELLAS, LEROY SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026563 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CHARLIE SPATAFORE PROPERTY (Circle One) <br /> Account Balance as of 3/9/2005: $0.00 �� q <br /> imle One) <br /> AlTransfer to ctive/Inaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Omer? Delete <br /> 2950-ENVIRON ASSESS PR0522619 EE0000997-HARLIN KNOLL Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknovAedge that all site,and/or project spec,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 /> Slate and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: .$155.00= Amount Paid 16 90— Date <br /> Payment Type ✓ Check Number i24 Received by 20-�-- <br /> REHS: JUKnn,,,.LR Dated/ / 0 S:f Account out: Date .3 1 IDS <br /> COMMENTS: <br /> \\phs-ehsq I-nt\apps\envisions\reports\5021.rpt <br />