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Date run 5/11/2004 2:29:11PN SAN JOAfN COUNTY ENVIRONMENTAL HEALEPARTMENT Report#5021 <br /> Run <br /> Facility Information as of 5/11/200 Pagel <br /> Record Selection Criteria: Facility ID FA0013435 <br /> Make changes/correctionsINFORMATIC in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <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 /> WorklBusiness 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 44368 q10 LDUtSiA0A ST. — P-m 44bl <br /> HOUSTON, TX 770024916 <br /> Care of {R.V-4ENK{NS._. 30T4 F EC <br /> Location Code APN: <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account IDNew Account ID: <br /> Mail in <br /> ZAccountt,'!)' <br /> Mail Invoices to: Owner / Facility / Account <br /> Account NamL OIL CO (circle one) <br /> Account Balance as of 5/11/2004: $920.70 <br /> (Circle One) <br /> Transfer to <br /> Active/Inactve <br /> Program/Elemen t and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2960-RWQCB CLEAN UP SITE(SLIC) PR0517454 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 hourlycharges 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: � f'f/Lf Tf co-gi�) fbi OtC-E Date 5— 0 <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 Received by <br /> REHS: Date / / Account out: Date_�/_LL/-py <br /> COMMENTS: <br /> \\Phs-ehsgl-nt\apps\Envisions\Reportsk502l.rpt • • <br />