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Date run 5/16/01 1:46:14PM SAUIN COUNTY PUBLIC HEALTH SES Report #: 0002 <br /> Run by Facility Information as of 5/16/01 Page #: 1 <br /> Record Selection Criteria: Facility ID FA0007884 <br /> Record to <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> OWNERSHIP CHANGE (date) <br /> OWNER FILE INFORMATION <br /> Owner to: OW0006521 New Owner ID <br /> Owner Name: T&S GROUP <br /> Owner DBA• <br /> Owner Address: 85 E TENTH ST <br /> TRACY, CA 95376- <br /> Home Phone: Not Specified <br /> Work/Bussness Phone: 327-000 <br /> Mailing Address: 85 E TENTH ST <br /> TRACY, CA 95376- <br /> Care of: T& S GROUP <br /> FACILITY FILE INFORMATION <br /> Facility to: FA0007884 <br /> Facility Name: LAUREL BROOK/SURLAND HOMES <br /> Location: 2532 DORSET LN LOTS 26,28 62 <br /> TRACY, CA 95376 <br /> Phone: 209-832-7000 <br /> Mailing Address: 4000 EXECUTIVE PKWY STE 400 <br /> SAN RAMON, CA 94583- <br /> care of: CHEVRON PIPE LINE CO <br /> Location Code: 03 -TRACY APNi <br /> Bos District: 005 - BEDFORD, LYNN SIC Code; <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0014507 New Account ID:: <br /> Maillnvoicesto: Account Mail Invoices to: Owner/Facility/Account <br /> Account Name: CHEVRON PIPELINE CO (Circle one) <br /> Account Balance as of 5/16/01: $0.00 <br /> (Circle One) <br /> UST(s) Transferto Active/Inactve <br /> PrograrrJElement and Description Record ID Employee ID and Name tus Linked New Owner? Delete <br /> 2960-RWQCB CLEAN UP SITE PRO508012 EE0000684-INFURNA Ac e Y N A 0 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific, <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this form I also certify that all <br /> operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: '$0.00= Amount Paid Date <br /> Water System to be T FER D: '$150.00= Amount Paid Date <br /> Payment Type Check Number Receipt Number Received by <br /> REHS: Date 15/ lee / U Account out: Date 06 / 01 l 0/ <br /> 1.0.0.89.00 <br />