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Date run 11/13/2002 10:01:151 SAN JO IN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 11/13/2^ Pagel <br /> Record Selection Criteria: Faclity ID FA0003155 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) - <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0002353 New Owner lD <br /> Owner Name FLOWERS, KORINNE <br /> Owner DBA THE OASIS CAFE r <br /> Owner Address PO BOX 1106 <br /> TRACY, CA 95378 y <br /> Home Phone 209-545-3146 <br /> Work/Business Phone 209-835-3182 <br /> Mailing Address PO BOX 1106 <br /> TRACY, CA 95378 <br /> Care of FLOWERS, KORINNE <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0003155 <br /> Facility Name THE OASIS CAFE & MARINA STORE <br /> Location 12450 W GRIMES RD <br /> TRACY, CA 95376 <br /> Phone 209-835-3182 <br /> Mailing Address PO$OX 41o(t (J Y l Wil {� <br /> TRACY, CA-953781-106 -1YUG.4 CA 5o <br /> Care of FLOWERS, KORINNE <br /> Location Code 03-TRACY APfN: <br /> BOS District 005- BEDFORD, LYNN SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002720 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name THE OASIS CAFE & MARINA STORE (Circle One) <br /> Account Balance as of 11/13/2002: $0.00 <br /> (Circle One) <br /> Transfer to <br /> AcIWe/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status Non Owner? Delete <br /> 1615-RETAIL MKT<2000 SO FT(PREPKGD ONLYPRO161213 EE0003361 -MARIBEL FLOHRSCHU Active Y N A I D <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO162217 EE0003361 -MARIBEL FLOHRSCHU-Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PRO511593 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2390-ABOVEGROUND TANK(SPCC) PR0516731 EE0000451 -STEVE SASSON Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPRO509305 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 4634-TNC WATER SYSTEM(ORTLY) WA0460998 EE0000753-WILLIE NG Active 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,PMS/EHD hourly charges associated with this <br /> facility or actNity,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 /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: '$155.00= Amount Paid Date <br /> Payment Type Check Number Receive <br /> REHS: Date / / Account out Date 1Ll��l G 2- <br /> COMMENTS:COMMENTS: <br /> \\Phs-ehsq I-nt\a pps\E n visions\Reports\5021.rpt <br />