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Rete run 8/1/2013 8:37:57AM SANJOWIN COUNTY ENVIRONMENTAL HEA*DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/1/2013 <br /> Record Selection Crilert FacilityID FA0021738 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0016097 New Owner ID : <br /> Owner Name PADILLA, MILA S <br /> Owner DBA <br /> Owner Address PO BOX 1036 <br /> TRACY, CA 953781036 <br /> Home Phone 209-832-7780 <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 1036 <br /> TRACY, CA 953781036 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0021738 <br /> Facility Name PROPOSED 7-11 #36084 VACANT LOT <br /> Location 620 ELEVENTH ST <br /> TRACY, CA 95376 <br /> Phone <br /> Mailing Address PO BOX 711 <br /> DALLAS, TX 95221 <br /> Care of <br /> Location Code 03-TRACY Alt Phone <br /> SOS District 005- ELLIOTT, BOB Fax <br /> APN 25025007 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name PADILLA, MILA <br /> Title OWNER <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0039488 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name STANTEC CONSULTING SERVICES INC (Circle One) <br /> Account Balance as of 8/1/2013: $-437.50 <br /> (Circle One) <br /> Transfer to AcliveAnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PRO537720 EE0001699-JOHNNY YOAKUM Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andior project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form I also certify that all operations will be perfoimed in accordance with all applicable Ordinance Codes andfor Standards and State and'or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />