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Date run 6121101 3:36:27PM SAN, 'kReport #: 5023QUIN COUNTY PUBLIC HEALTH SER ES Page #: 1 <br /> Run bye Facility Information as of 6121101 <br /> Record Selection Criteria: Facility ID FA0006779 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID: OW0006051 New Owner ID <br /> Owner Name: CHEVRON PIPE LINE CO <br /> Owner DBA: <br /> Owner Address: 6001 BOLLINGER CANYON RD <br /> SAN RAMON, CA 94583 <br /> Home Phone: 925-842-1341 <br /> Work/Business Phone: Not Specified <br /> Mailing Address: PO BOX 6012 <br /> SAN RAMON, CA 945830712 <br /> Care of: ROBERT D MIHALOVICH <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0006779 <br /> Facility Name: DIVIDEND PROPERTY <br /> Location. 13170 W GRANT LINE RD <br /> TRACY, CA 95376 <br /> Phone: 408-246-5001 <br /> Mailing Address: PO BOX 6012 <br /> SAN RAMON, CA 945830712 <br /> Care of: ROBERT D MIHALOVICH <br /> Location Code: 99- UNINCORPORATED AREA APN: <br /> BOS District: Q05 - BEDFORD, LYNN SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0009315 New Account ID: <br /> Mail Invoices to: Account Mail Invoices to: Owner I Facility 1 Account <br /> Account Name: CHEVRON PIPE LINE CO (Circle One) <br /> Account Balance as of 6121101: $0.00 <br /> (Circle One) <br /> Transfer to Activelln9c e <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2960-RWQCB CLEAN UP SITE PRO505432 EE0000684-MICHAEL INFURNA ACfi Ve Y N A U 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 Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 I <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date 1 / <br /> Water System to be TRANSFERED: "$150.00= Amount Paid Date 1 1 <br /> ! ) <br /> Payment Type Check Number Credit Card Number Received by / <br /> REHS: _ __ _•_- Date 1 L l I f Account out: Date �Y 1 L 1 '0 <br /> COMMENTS: <br /> I1PHS-EHSQL-NTL4PPS1Envisions\Client AccesslENVIS10N1REPO <br />