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Date run 9/11/2013 12:27:24PI SAN JO IN COUNTY ENVIRONMENTAL HEA14DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9111/2013 <br /> Record Selection Criteria: Facility ID FA0021799 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0014441 New Owner ID <br /> owner Name RADC ENTERPRISES INC <br /> Owner DBA <br /> Owner Address 1040 N BENSON AVE <br /> UPLAND, CA 91786 <br /> Home Phone 909-717-5502 <br /> Work/Business Phone 909-394-4728 <br /> Mailing Address 1040 N BENSON AVE <br /> UPLAND, CA 91786 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021799 <br /> Facility Name SHELL GAS STATION/ANABI OIL <br /> Location 3725 TRACY BLVD <br /> TRACY, CA 95304 <br /> Phone 909-376-4445 <br /> Mailing Address 1040 N BENSON AVE <br /> UPLAND, CA 91786 <br /> Care of RADC NORTH INC/SAM ANABI <br /> Location Code 03-TRACY Alt Phone <br /> BOB District 005-ELLIOTT, BOB Fax <br /> APN 21217030 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name RADC NORTH INC/SAM ANABI <br /> Title <br /> Day Phone 909-376-4445 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0039649 NewAccount ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name SHELL GAS STATION/ANABI OIL (Circle One) <br /> Account Balance as of 9/11/2013: $-125.00 <br /> (Circle One) <br /> Transfer to Activennactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0537796 EE0001699-JOHNNY YOAKUM Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor protect speck,PHSIEHD hourly charges associated with this facility <br /> or activity will be billetl to the party identified as the OWNER on this form l also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <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 /> REHS: Date /_/ Account out: Date <br /> COMMENTS: <br />