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Report#5021 <br /> Date run 4/10/2009 9:17:24AN ;FA0016,494 <br /> AN JOA ;Facility <br /> TY ENVIRONMENTAL HEAL ARTMENT Pagel <br /> Run by Information as of 4/10/2009 <br /> Rewrd Seleaion cdtena: Facility ID <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0013008 New Owner ID <br /> Owner Name LUCKEY,TOM <br /> Owner DBA TCN PROPERTIES <br /> Owner Address 17287 S MANTHEY RD <br /> LATHROP, CA 95330 <br /> Home Phone 209-982-9564 <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 310 <br /> LATHROP, CA 95330 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0016494 <br /> Facility Name RECYCLED WATER BASIN D <br /> Location 15340 MCKINLEY AVE <br /> LATHROP, CA 95330 <br /> Phone <br /> Mailing Address PO BOX 310 <br /> LATHROP, CA 95330 <br /> care of LUCKEY,TOM <br /> Location Code 07-LATHROP Alt Phone <br /> BOS District 003-MOW,VICTOR Fax <br /> APN 19806016 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name LUCKEY, TOM <br /> Title <br /> Day Phone 209-982-9564 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> New Account ID: <br /> Account ID 2APc6unt <br /> 00 `a- <br /> Mail Invoices to Mail Invoices to: Owner I Facility / Account <br /> ciroleone) <br /> Account NamY OF LATHROP <br /> Account Balance as of 4/19: $0.00 (Circle one) <br /> Transfer to Activeflnacive <br /> Program/Element and Description E0000684 <br /> ID Employee ID and Name <br /> Status New Owner? Delete <br /> PR0524584 EE0000684-MICHAEL INFURNA Active Y N A I D <br /> 2965-WATER QUALITY SITE PROJECT <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this forth. 1 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 /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: <br /> Date_/_I_ Account out: Date <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />