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Date run 8/25/2003 1:46:50PA SAN JO.; _JIN COUNTY ENVIRONMENTAL HEA. DEPARTMENT Report#sort j <br /> Run by --"� Pagel <br /> Facility Information as of 8/25/2003 <br /> Record Selection Criteria: Facility ID FA0013911 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0011001 New Owner ID <br /> Owner Name ALI, SAIYED S <br /> Owner DBA CALTRANS <br /> Owner Address 1976 E CHARTER WAY <br /> STOCKTON, CA 95205 <br /> Home Phone 209_948-7873 <br /> WorktBusiness Phone Not Specified <br /> Mailing Address PO BOX 2048 <br /> STOCKTON, CA 95201 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013911 <br /> Facility Name CALTRANS TRACY MAINTENANCE STATI f <br /> Location 2005 KROHN RD <br /> TRACY, CA 95376 <br /> Phone <br /> Mailing Address 1326 N MARKET BLVD <br /> SACRAMENTO, CA 95834 <br /> Care of MARTHA ADAMES <br /> Location Code APN: <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0023467 New Account ID: <br /> Mail Invoices to Accoutt� <br /> t Mail Invoices to: Owner / Facility ! Account <br /> Account Name IT CON (Circle One) <br /> Account Balance as of 8/25/2003 <br /> {Circ/ <br /> Transfer to Ac Inactve <br /> ProgramfElement and Description Record ID Employee ID and Name Status New Owner? <br /> 3030-UI CONTROL PROG SITE PR0518440 EE0000684-MIC`HAEL INFURNA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,ac�Cnowledge that all site,and/or project specific.PHSIEHD 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 andlor Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date I I <br /> Water System to be TRANSFERED: '$155.00= Amount laid Date / I <br /> Payment Type heck Number Received by <br /> REHS: Date I I Account out: [ Date�l 2/A*I t <br /> COMMENTS: <br /> I1Phs-ehsgl-nt%apps\EnvisionslReports15021.rpt <br />