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Run by : SANDY A Joaquin County PHS/EHD • Report #5021 FACILITY INFORMATION as of 10/14/96 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Make changes/corrections in RED pen or pencil: OWNER FILE INFORMATION INFORMATION CHANGE (date): OWNERSHIP CHANGE (date): OWNER ID: 004745 New Owner ID: 00 owner Name: TRACY, CITY OF Owner DBA: owner Address: 520 TRACY BLVD TRACY, CA 95376 Home Phone: 209-836-4420 Soc Sec# / Tax ID#: ownership Type: 01 CORPORATION Mailing Address: 520 TRACY BLVD care of: TRACY, CITY OF TRACY, CA 95376 FACILITY FILE INFORMATION FACILITY ID: 006989 Facility Name: ALDEN PARK AREA RESIDENTS Location: CHESTNUT, PALM & LOCUST TRACY 95376 Phone: Mailing Address: 520 TRACY BLVD care of: TRACY, CITY OF TRACY, CA 95376 Location Code: APN: SOS District: SIC Code: ACCOUNTS RECEIVABLE FILE INFORMATION ACCOUNT ID: 0009999C�1i�'P"Y�e 1-tvw� New Account ID: 000 l,p,A7 U.lil'1 I<4'lie Mail Invoices to: Account C roJ - Mail Invoices to: Owner / Facility / Account Account Name: CHEVRON PIPE LINE C11,,�1�h�r. (circle one) Account Balance as of 10/14/96 : $156. 00 015 ��C/II Dn- ND -rhefG CtUl ov'p . (circle one) Record UST(s) Transfer to Activate / Inactivate P/E Description ID Employee Status Linked new owner? Delete - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 2960 RWACB CLEAN UP SITE PR505769 0684 INFURNA ACTIVE Y N A I D - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that alL site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this form. I also certify that all operations will be performed in accordance with aLL applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PR Records to be TRANSFERED: x $20.00 = Amount Paid Date_/ / Water System to be TRANSFERED: x $150.00 = Amount Paid Date—/—/— Payment ate_/ /Payment Type Check # Recvd by ____ ____________ RENS or COUNTER SUPV Date—/—/— ACCT out: Date_ / / UNIT/File: