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Date run 5/11/2004 2:28:55PN SAN JOE` AN COUNTY ENVIRONMENTAL HEAL' 7EPARTMENT Report#5021 <br /> Run by � Pagel <br /> Facility Information as of 5/11/2004 <br /> Record Selection Criteria: Facility ID FA0014798 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0010479 New Owner ID <br /> Owner Name TRIMARK COMMUNITIES <br /> Owner DBA <br /> Owner Address 3120 TRACY BLVD STE A <br /> TRACY, CA 95376 <br /> Home Phone 209-836-1560 <br /> Work/Business Phone 209-836-1759 <br /> Mailing Address 3120 TRACY BLVD STE A <br /> TRACY, CA 95376 <br /> Care of STANLEY PLOOF <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014798 <br /> Facility Name MOUNTAIN HOUSE NEIGHBORHOOD E <br /> Location MASCOT& MARINA BLVD <br /> TRACY, CA 95376 n <br /> Phone 5 klGLL. Q t L Pia s WS; <br /> Mailing Address 3120 TRACY BLVD <br /> TRACY, CA 95376 <br /> Care of STANLEY R PLOOF <br /> Location Code 03-TRACY APN:209-050-08 <br /> BOS District Cpl 0-A � SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION ✓' b0� <br /> Account lD AR0-02.5211_ j' � New Account ID: <br /> Mail Invoice Account �l � J� �2 Mail Invoices to: Owner / Facility / Account <br /> Account Na�LL OIL COMPANY n''"`, 4W*,, ,4162 (Circle One) <br /> Account Balance as of 5/11/2004. $186.40 ��((1- I'�Ir' dr ��,1 <br /> 5 �Z q 0 /I (Circle One) <br /> III``���"� 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) PR0521796 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. �y �" �� &�i !� <br /> oe <br /> APPLICANT'S SIGNATURE: ��% � � tK� '�=''� 7yk �� "Date 5 / 6 t / V / <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: *$155.00= Amount Paid Date <br /> Payment Type Check Number Received by _ <br /> REHS: Date / / Account out: - Date ` / l( / f <br /> COMMENTS: <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rpt <br />