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Date run 10/2/2003 3:09:11 PA SAN J( iUIN COUNTY ENVIRONMENTAL HE, H DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/2/2003 <br /> Record Selection Criteria: Facility ID FA0013927 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0011015 New Owner ID <br /> Owner Name BACKLUND, DALE <br /> Owner DBA DOW <br /> Owner Address 400 W GANDY DANCER <br /> TRACY, CA 95377 <br /> Home Phone 209-836-4440 <br /> Work/Business Phone Not Specified <br /> Mailing Address 400 W GANDY DANCER <br /> TRACY, CA 95377 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013927 <br /> Facility Name DOW <br /> Location 400 W GANDY DANCER <br /> TRACY, CA 95377 <br /> Phone <br /> Mailing Address 400 W GANDY DANCER <br /> TRACY, CA 95377 <br /> Care of <br /> Location Code APN: <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0023512 t,g� NewAccount ID: <br /> Mail Invoices to Account l U Mail Invoices to: Owner / Facility ! Account <br /> Account Name URS (Circle One) <br /> Account Balance as of 10/2/200 : <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2960-RWQCB CLEAN UP SITE(SLIC) PR0518474 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 speck,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 /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$155.00= Amount Paid D <br /> Payment Type Check Numbered by <br /> REHS: Date / / Account out: Date ! / 9-- <br /> COMMENTS: <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rpt <br />