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Date tan 11/12/2014 11:34:18/ SAN JOA 'IN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by "/ Panel <br /> Facility Information as of 11/12/20 4 <br /> Record Selection Criteria Facility ID FA0003299 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : <br /> Owner lD OW0002252 New Owner ID <br /> Owner Name TRACY GOLF &COUNTRY CLUB <br /> Owner DBA TRACY GOLF & CC (CLUBHOUSE) <br /> Owner Address 35200 S CHRISMAN RD <br /> TRACY, CA 95377 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-835-9320 <br /> Mailing Address 35200 S CHRISMAN RD <br /> TRACY, CA 95377 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0003299 10181091 <br /> Facility Name TRACY GOLF & COUNTRY CC (CLUBHOUS <br /> Location 35200 S CHRISMAN RD <br /> TRACY, CA 95377 <br /> Phone 209-835-9320 x <br /> Mailing Address 35200 S CHRISMAN RD <br /> TRACY, CA 95377 <br /> Care of Tracy Golf&CC <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 005- ELLIOTT, BOB Fax <br /> APN 25327019 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002873 New Account ID. <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name TRACY GOLF & COUNTRY CC (CLUBHOUSE) (circle one) <br /> Account Balance as of 11/12/2014: $0.00 <br /> (Circle One) <br /> Transfer to Actio lnai <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> /f)1621 -BAR w/o FOOD PREP PRO161479 EE0001420-MELISSA NISSIM Active Y N A I D <br /> )A 0-HMBP-Common Materials PRO521160 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512458 EEOOOOOOO-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PRO505718 EE0000005-FATINAH ZAREEF Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510170 EEOOOOOOO-HAZ MAT SJC OES Inactive Y N A I D <br /> 3699-POOL/SPA-OUT OF SERVICE PR0360620 EE0001084-STEPHANIE RAMIREZ Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532458 Inactive Y N A I D <br /> 4633-TNC WATER SYSTEM WA0461017 EE0005838-ADRIENNE ELLSAESSER Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specifc,PHS/l hourly charges associated with Nis facility <br /> or aceLt�ivilywiill be billedto the party identified as the OWNER on this form. Ialso candy that <br /> taall ooperab(o/r/p/j, Il be pertorm,id in accord withh 111�apJ,plicable rdma C sand7ardTandState arri <br /> I Lewis <br /> P/✓tidMO � <br /> APPLICANTS SIGNATURE: (/ y �- lrVV\\ Date / / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date / I <br /> Payment Type t-Check Number Rem e <br /> REHS: UAB Date�/��/ l y_ Account out: Date <br /> COMMENTS: <br />