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Date run 10/17/2003 3:44:03P SAN, QUIN COUNTY ENVIRONMENTAL HL TH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/17/2003 <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 <br /> Phone <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 SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0025211 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name SHELL OIL COMPANY (Circle One) <br /> Account Balance as of 10/17/2003: $-8.90 <br /> COne) <br /> Transfer to �Act�, r <br /> ve/lnactve <br /> Program/Element and Description Record I O� Employee ID and Name zK— VK St s „ _ New Owner? Delete <br /> 250-ENVIRON ASSESS PR0521796 EE0000684-MICH INFURNA Ac' e 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/tole T NSFERED: '$155.00= Amount Paid Date <br /> Payment Typ Check Number R Ive,d by <br /> REHS: Date�c) Date J/ / Account out: ` / L/� <br /> COMMENTS: <br /> \\Phs-ehsql-nt\a pps\Envisions\Reports\502 1.rpt <br />