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Date run 10/24/2011 8:56:55,4 SAN JO,' 1IN COUNTY ENVIRONMENTAL HEA1 —'A DEPARTMENT Report#5021 <br /> Run by 4006 PagelFacility Information as of 10/24/20 <br /> Record Selection Criteria: Facility ID FA0012225 <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 OW0004890 New Owner ID <br /> Owner Name POMBO, ERNEST J JR <br /> Owner DBA POMBO REAL ESTATE <br /> Owner Address 24100 S LAMMERS ROAD <br /> TRACY, CA 95376 <br /> Home Phone Not Specified 3S— S—Z 9 c <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 805 <br /> TRACY, CA 95376 <br /> Care of ERNEST J POMBO JR <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012225 D .n�� to"o zz�) <br /> Facility Name POMBO REAE <br /> EST EPE if ' �• `� <br /> Location 1755 W 11 TH ST <br /> TRACY, CA 95376 <br /> Phone 209-835-4949 S(.4 _cam , 1 <br /> Mailing Address p$B$)F-805 lt-ns 7l f ST <br /> TRACY, CA 95375 of 5-3 -7�o <br /> Care of ERNEST J POMBO JR <br /> Location Code 03 -TRACY Alt Phone <br /> BOS District 005- ORNELLAS, LEROY Fax <br /> APN 23217020 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION n� L <br /> Contact Name 4% �— <br /> Title <br /> Day Phone <br /> Night Phone ?.0 -7 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0019735 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility Account <br /> Account Name (Circle one) <br /> Account Balance as of 10/24/2011: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0515574 , EOL 'E6 6Y 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 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 and/or Standards and <br /> Slate and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date l l 1/ <br /> Program Records to be TRANSFERED: $25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received b <br /> REHS: Date / / Account out: <br /> COMMENTS: <br /> \\eh-env\e n vision\reports\5021.rpt <br />