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Date run 11/5/2043 9:05:32AK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by I Pagel <br /> Facility Information as of 11/5/2003 <br /> Record Selection Criteria: Facility ID FA0013993 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0006569 New Owner ID <br /> Owner Name DOBLER, LOUIE <br /> Owner DBA <br /> Owner Address 276 W 20TH ST <br /> TRACY, CA 95376 <br /> Home Phone 209-836-3316 <br /> Work/Business Phone Not Specified <br /> Mailing Address 276 W 20TH ST <br /> TRACY, CA 95376 <br /> Care of LOUIE DOBLER <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013993 <br /> Facility Name FORMER TRACY PUMP STATION <br /> Location 14821 W GRANT LINE RD <br /> TRACY, CA 95376 <br /> Phone 209-836-3316 <br /> Mailing Address 276 W 20TH ST <br /> TRACY, CA 95376 <br /> Care of LOUIE DOBLER <br /> Location Code 03-TRACY APN: <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0023674 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CHEVRON ENVIRONMENTAL MGMT CO (Circle One) <br /> Account B f 11/5/2003: $0.00 <br /> 2� ,(Oo (Circle One) <br /> V" Com- Transfer to Active/Inactve <br /> ogra escription Record ID / Employee ID and Name Status ✓ New Owner? Delete <br /> 3P86- <br /> ENV; ASSESS PR0518596 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 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 a TRANSFERED: *$155.00= Amount Paid Date / / <br /> Payment Typ Check Number Re <br /> REHS: Date P / Account out: e rLl_ 1�3 <br /> COMMENTS: <br /> y I <br /> \\Phs-ehsq I-nt\apps\Envisions\Reports\5021.rpt <br />