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`Date run 11/17/2004 3:00:15P SAN JOA"UIN COUNTY ENVIRONMENTAL HEAL-7f DEPARTMENT Report#5021 <br /> r Run by j y^ t Facility Information as of 11/17/20 Pagel <br /> Record Selection Criteria: Facility ID FA0004493 <br /> i <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0003408 New Owner ID <br /> Owner Name GLOVER, DR A R <br /> Owner DBA PIEDMONT LUMBER <br /> Owner Address PO BOX 1055 <br /> TRACY, CA 95378 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 7675 W 11 TH ST <br /> TRACY, CA .95376 <br /> Care of <br /> FACILITY FILE INFORMATION j <br /> Facility ID FA0004493 <br /> Facility Name PIEDMONT LUMBER <br /> Location 7675 W ELEVENTH ST <br /> TRACY, CA 95376 <br /> Phone 209-832-8400 <br /> Mailing Address �ig-7.5-W-"I+,ST t' x S r <br /> Care of <br /> Location Code 99-UNINCORPORATED AREA APN:$gP}EDJV-76--o25,?n <br /> BOS District 005- ORNELLAS, LEROY SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004175 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name GLOVER, DR A R. (Circle One) <br /> Account Balance as of 11/17/2004: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0512268 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0520000 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPRO509980 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 4630-NTNC WATER.SYSTEM r WA0461336 EE0001699-JOHNNY YOAKUM t" ctive`7 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 Recei e I b <br /> REHS: Date / / Account out: <br /> COMMENTS: <br /> \\phs-ehsg l-nt\apps\envisions\reports\5021.rpt <br />