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Date run 4/19/2010 1:52:25PN SAN JOY 'IN COUNTY ENVIRONMENTAL HEAL' 'DEPARTMENT Report#5021 <br /> Run by 10-� � Pagel <br /> Facility Information as of 4/19/2010 <br /> Record Selection Criteria: Facility ID FA0006510 <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 OW0001860 New Owner ID <br /> Owner Name DELTA BLOOD BANK <br /> Owner DBA DELTA BLOOD BANK <br /> Owner Address 65 N COMMERCE ST <br /> STOCKTON, CA 95202 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-943-3830 <br /> Mailing Address PO BOX 800 <br /> STOCKTON, CA 95201 <br /> Care of DELTA BLOOD BANK <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0006510 <br /> Facility Name CHEVRON PIPELINE <br /> Location GRANT LINE RD <br /> TRACY, CA 95376 <br /> Phone 510-676-6677 <br /> Mailing Address 6111 BOLLINGER CANYON RD <br /> SAN RAMON, CA 94583 <br /> Care of MACLEOD, JOHN <br /> Location Code 03 -TRACY Alt Phone <br /> BOS District 005-ORNELLAS, LEROY Fax <br /> APN 214-020-10 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name DELTA BLOOD BANK <br /> Title <br /> Day Phone 209-943-3830 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0008649 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CHEVRON PIPELINE (Circle One) <br /> Account Balance as of 4/19/2010: $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 /> 2960-RWQCB SITE PR0505070 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: *$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />