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Date run : 813/00 11:24:30AM <br /> Run by SMARTINEZ SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> Facility Information as Of 813100 Report #: 0002 <br /> Record Selection Criteria: Facility ID FA0012528 Page #: <br /> 1 <br /> Rec rd ID <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE (date) : <br /> Owner ID: OW0009732 <br /> Owner Name; DIVIDEND LIQUIDATION TRUSTS New Owner ID <br /> Owner DBA• <br /> Owner Address; 275 SARATOGA AVE 105 <br /> SANTA CLARA, CA 95050- <br /> Home Phone: 408-246-5001 <br /> WOrk/Bussness Phone: Not Specified <br /> Mailing Address: 275 SARATOGA AVE 105 <br /> SANTA CLARA, CA 95050- <br /> Care of: DICK OLIVER <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0012528 <br /> Facility Name: DIVIDEND LIQUIDATION TRUSTS <br /> Location: 13170 GRANTLINE RD <br /> Phone: TRACY, CA 95376 <br /> Mailing Address: 275 SARATOGA AVE STE 105 <br /> SANTA CLARA, CA 95050- <br /> Care of: RICHARD B OLIVER <br /> Location Code: APN. <br /> BOS District; SIC Code; <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0020524 New Account ID:• <br /> Mail invoices to: Facility Mail Invoices to: Owner 1 Facility I Account <br /> Account Name: DIVIDEND LIQUIDATION TRUSTS (Circle One) <br /> Account Balance as of 813/00: $522.60 <br /> (Circle One) <br /> UST(s) Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status Linked New Owner? Delete <br /> 2951 -UGT-CAPPRO516241 EE0000684-INFURNA Active Y N A 0 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or <br /> project specific,PHSIEHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this <br /> form. 1 also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and State and/or Federal <br /> Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: "$0.00= Amount Paid Date 1 1 <br /> Water Syste to b T NSFERED: "$150.00= Amount Paid Date 1 I <br /> Payment Ty Check Number Receipt Number Received by <br /> REHS: Date 1 Account out: Date 91 / /dU <br /> r <br /> 1.0.0.89.00 <br />