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x <br /> q PHS/EHD Report ##5021 <br /> Run by : STAFF San Joaquin County <br /> FACILITY INFORMATION as of 10/24/97 ------ -------- ------ <br /> __ __ <br /> ------ <br /> ---"'----__ - -_ ----------------- <br /> Make changes/corrections in RED pen or pend <br /> INFORMATION CHANGE (date) : <br /> _OWNER FILE INFORMATION OWNERSHIP'CHANGE {date) <br /> OWNER ID: 005961 New Owner ID: 00 <br /> Owner Name: NEW TRACY PARK S I X <br /> Owner DBA: <br /> Owner Address: 7510 SHORELINE DR STE B-1 <br /> STOCKTON, CA 95219 r <br /> Home Phone: <br />_ Soc Sec# / Tax TD#: <br /> Ownership Type: 01 CORPORATION <br /> 10 SHORELINE DR STE B-1 <br /> Mailing Address_ 75 <br /> Care of: <br /> STOCKTON, CA 95219 <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 007241 <br /> Facility Name: PARK SIX OFFICES <br /> Location: 2680 N TRACY BLVD <br /> TRACY 95376 <br /> Phone: <br /> Mailing Address: 2680 N TRACY BLVD <br /> Care of: <br /> TRACY, CA 95376 <br /> Location Code: 0 3 APN: <br /> BOS District: 005 SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0010627 New Account ID: 000 <br /> Mail Invoices to: ACCount Mail Invoices to: Owner / Facility / Account <br /> Account Name: FIRST INTERSTATE BANK (Circle one) <br /> Account Balance as of 10/24/97 : $0 . 00 (Circle one) <br /> Record UST(s) Transfer to Activate / inactivate <br /> P/E Description ID Employee Status Linked new owner? Delete <br /> --------------------------------- ------------------------- -------------------- <br /> 2950 ENVIRON ASSESS PR506163 0684 INFURNA INACTIVE Y N A I D <br /> -------------------------------------------------------------------------------- <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. I also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> ----'------------------------------------------------------------------ --------- <br /> PR Records to be TRANSFERED: x $20.00 = Amount Paid Date-/-/ <br /> Water System to be TRANSFERED: x $150.00 = Amount Paid Date-/-/ <br /> Payment Type Check # Recvd by <br /> RENS or COUNTER SUPV: Date-/-/ ACCT cut: Date-/-/ UNIT/File:-/-/ <br /> i� <br />