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Date run 6/18/2014 1SAN JO1`,)IN COUNTY ENVIRONMENTAL HEAI>✓DEPARTMENT <br /> Repon#5021 <br /> Pagel <br /> Run by Facility Information as of 6/18/2014 <br /> Record Selection Criteria: Facility ID FA0002968 <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: 28 SSN/Fed Tax lD <br /> Owner ID OW0001946 New Owner ID <br /> Owner Name TRACY UNIFIED SCHOOL DIST <br /> owner DBA TRACY UNIFIED SCHOOL DISTRICT <br /> Owner Address 1975 W LOWELL AVE <br /> TRACY, CA 95376 <br /> Home Phone 209-830-3200 <br /> Work/Business Phone 209-830-3200 <br /> Mailing Address 1875 W LOWELL AVE <br /> TRACY, CA 95376 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0002968 <br /> Facility Name TRACY USD-JACOBSON SCHOOL <br /> Location 1750 W KAVANAUGH AVE <br /> TRACY, CA 95376 <br /> Phone 209-831-5053 <br /> Mailing Address 3t5--E-j1-T+{- <br /> TRACY, CA 95376 11 cc <br /> Care of 027 JCX J �c S <br /> Location Code 03 -TRACY Alt Phone <br /> BOS District 005 - ELLIOTT. BOB Fax <br /> APN 21407002 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name TRACY UNIFIED SCHOOL DIST <br /> Title <br /> Day Phone 209-831-5053 <br /> Night Phone 209-835-8000 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002530New Account ID: <br /> Maillnvoicesto Gyy�-T�1�t. Mail Invoices to. Owner / Facility / Account <br /> Account Name TRACY UNIFIED SCHOOL DIST (Cede One) <br /> Account Balance as of 6/18/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/InacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner' Delete <br /> 1632-EXEMPT FOOD PRO162579 EE0001420-MELISSA NISSIM Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent attains,acknowledge that all site,ander project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on Nis fano. I also certify that all operations will be perromed in accordance with ell applicable Ordinance Codes ardor Standards and State andfor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: 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 Check Number Re by <br /> REHS: Date / / Account out: Date_5!�_/-4— <br /> COMMENTS: <br />