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Date run 5/23/2013 2:01:35PN SAN J 2UIN COUNTY ENVIRONMENTAL HE, H DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 5/23/2013 <br /> Record Selection Criteria: Facility ID FA0013993 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> SSN/Fed Tax ID <br /> Owner ID OW0006569 New Owner ID <br /> Owner Name DOBLER, LOUIE -4 <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 Site Mitigation Facility <br /> Facility ID/CERS ID FA0013993 <br /> Facility Name TRACY PUMP STATION <br /> oe 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 Alt Phone <br /> BOS District Fax <br /> APN 20919006 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name FORMER TRACY PUMP STATION <br /> Title <br /> Day Phone 209-836-3316 <br /> Night Phone <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 SAIC (Circle One) <br /> Account Balance as of 5/23/2013: $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 /> 2960-RWQCB SITE 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 facility <br /> 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 Ordinance Codes and/or Standards and State ancVor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <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 by <br /> RENS: Date / / Account out: 7.-&—Date <br /> COMMENTS: <br />