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Dale run 7/2/2010 2:29:05PM SAN JOIN COUNTY ENVIRONMENTAL HEA j*DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 7/2/2010 <br /> Record Selection Criteria: Facility ID FA0013435 <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 OW0010573 New Owner ID <br /> Owner Name CORLISS, DAVE <br /> Owner DBA <br /> Owner Address 43 QUAIL CT <br /> WALNUT CREEK, CA 94596 <br /> Home Phone 925-977-1925 <br /> Work/Business Phone Not Specified <br /> Mailing Address 43 QUAIL CT <br /> WALNUT CREEK, CA 94596 <br /> Care of DAVE CORLISS <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013435 <br /> Facility Name SHELL PIPELINE(FORMER) <br /> Location HANSEN RD <br /> TRACY, CA 95376 <br /> Phone 925-977-1925 <br /> Mailing Address 910 LOUISIANA ST RM#4482D <br /> HOUSTON, TX 770024916 <br /> Care of BETH REEVES <br /> Location Code Aft Phone <br /> BOS District Fax <br /> APN Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name DAVE CORLISS <br /> Title - <br /> Day Phone 925-977-1925 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022451 New Account ID: <br /> Mail Invoices to Account _ Mail Invoices to: Owner / Facility / Account <br /> Account Name SLLE+L OIL CO INC#300562 (Circle One) <br /> Account Balance as of 7/2/2010: $345.00 <br /> (Circle One) <br /> Program/Element and DescriptionReartl ID Employee ID and Name Status Transfer to Acgvednaclve <br /> New Omer? Delete <br /> 2960-RWOCB SITE PRO617454 EE0000684-MICHAEL INFURNA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,anti/or project specific.PHS/EHD hourly charges associated with this <br /> facility a activitywill be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in eccordancewith all applicable Ordinece Codes and/or Standards and <br /> State andlor Federal Laws. /� <br /> APPLICANT'S SIGNATURE: P. e a' '6�e-r�.ltJ� 3 Q -1�{ �- c!1\ Date _LLL—Z / <br /> Program Records to be TRANSFERED: •$20.00= Amount Paid Date <br /> Water System to b SF RED: •$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> RENS: Date / / 10 Account out: Q,,- Date, -_L\D <br /> COMMENTS: <br /> \\eh-env\envisiontreports\5021.rpt <br />