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R•,nby : STAFF sa joaquin County PHS/EHD " Report #5021 <br /> FACILITY INFORMATION as of 09/03/98 <br /> - ---- - - - - - - -- - - - - --- ----------------------------------------------------------- <br /> Make changes/corrections in RED pen or pencil: <br /> OWNER FILE INFORMATION INFORMATION CHANGE (date) ; <br /> OWNERSHIP CHANGE (date) : <br /> OWNER ID: 006521 New owner ID: 00 <br /> Owner Name: T & S GROUP <br /> Owner DHA: <br /> Owner Address: 85 E TENTH ST <br /> TRACY, CA 95376 <br /> Home Phone: <br /> Soc Sec# / Tax ID#: <br /> Ownership Type: 01 CORPORATION <br /> Mailing Address: 85 E TENTH ST <br /> Care of: T & S GROUP <br /> TRACY, CA 95376 <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 007884 <br /> Facility Name: LAUREL BROOK <br /> Location: DORSET LN LOTS 26, 28 62 <br /> TRACY 95376 <br /> Phone: 209-832-7000 <br /> Mailing Address: 4000 EXECUTIVE PKWY STE 400 <br /> Care of: CHEVRON PIPE LINE CO <br /> SAN RAMON, CA 94583 <br /> Location Code: 0 3 APN: <br /> BOB District: SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0014507 New Account ID: 000 <br /> Mail Invoices to: Account Mail Invoices to: Owner / Facility / Account <br /> Account Name: CHEVRON PIPE LINE CO (Circle one) <br /> Account Balance as of 09/03/98 : $257 .40 (Circle one) <br /> Record UST(a) Transfer to Activate / Inactivate <br /> P/E Description ID Employee Status Linked new owner? Delete <br /> ------------------------------------------------------------------------------- <br /> 2950 ENVIRON ASSESS PR508012 0684 INFURNA ACTIVE Y N A I D <br /> ------------------------------------------------------------------------------- <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. I also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> _______________ -________-----_-________ ____--_____________ <br /> PR Records to be TRANSFERED: x $20.00 - Amount Paid Data—/—/- <br /> Water <br /> ate / /- <br /> Water System to be TRANSFERED: x $150.00 = Amount Paid Date—/—/- <br /> Payment <br /> ate_/ /Payment Type Check # Recvd by <br /> __ -_______ ____________ _______ ________________ <br /> RENS or COUNTER SUPV: Date/_ ACCT out: _ Date /_ UNIT/File:_/_/_ <br />