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DaleFm 411/2002 12:51:12PI SAN JOAQV -'COUNTY ENVIRONMENTAL HEALTII '.PARTMENT Report 05021 <br />Runby [ n `� Pape) <br />Facility Information as of 4/1112002 <br />Record Selection Criteria: Facility to FA0012702 <br />Make changes/corrections in RED ink or pencil. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (dale) <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0009892 <br />Owner Name <br />BARRETH, STEVEN H <br />Owner DBA <br />TRI VALLEY LINE X <br />Owner Address <br />1014 MADSEN DR <br />Phone <br />RIPON, CA 95366 <br />Home Phone <br />209-599-9279 <br />Work/Business Phone <br />209-814-1117 <br />Mailing Address 1014 MADSEN DR <br />RIPON, CA 95366 <br />Care of BARRETH, STEVEN H <br />FACILITY FILE INFORMATION <br />New Owner ID : <br />Facility ID <br />FA00127O2 <br />Facility Name <br />TRI VALLEY LINE X <br />Location <br />4220 COMMERCIAL DR V <br />TRACY, CA 95376 <br />Phone <br />209-814-1117 - Mo Oflr_ Q/� <br />ev^-M F -W �I <br />Mailing Address <br />1014 MADSEN DAilo <br />RIPON, CA 95366 <br />Care of <br />STEVEN H BARRETH <br />Location Code <br />03 -TRACY <br />BOS District <br />005 - BEDFORD, LYNN <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0021140 <br />Mail Invoices to Facility <br />Account Name TRI VALLEY LINE X <br />Account Balance as of 4/11/2002: $217.50 <br />Progra ntElemem and Description <br />Record ID Employee ID and Name <br />APN: <br />SIC Code: <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Cade One) <br />(Clicle One) <br />Transfer to Aelivednacbm <br />Status New Ownel9 Delete <br />2220 - SM HW GEN <5 TONSlYR PR0516603 EE0000451 - STEVE SASSON Active Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SERVICE FPR0516604 EE0000451 - STEVE SASSON Active Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I. the undersigned owner, operator or agent of same, ackhawledge that all site, mdlor project specific, PHS/EHD bou lycharges associated with this <br />facility or activity we he billed to the parry Idenitlled as the OWNER on this form. I also certgy that all operations will be performed In accordance with all applicable Ordinate Codes andfor Standards and <br />State andlor Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: <br />COMMMEE(N�]TSS�/tn��''� j�y.- <br />1 r <br />jw (MAJ"w <br />\\Phs-ehsgl.nl\apps\Envisions\Reports\5021.rpt <br />• $20.00 = <br />$155.00 = <br />Date —/—/ <br />Amount Paid Date <br />Amount Paid Date _ <br />Received by _ <br />Dale _/_/ Account out: <br />h (0 a ft -kw <br />Date <br />AA)t. /'till (,) fli-t li <br />