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Date run 10/11/2005 9:29:15A SAN JO N COUNTY ENVIRONMENTAL HEAIOPEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/11/2005 <br /> Record Selection Criteria: Facility ID FA0007884 <br /> Make changes/corrections in RED Ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0006521 New Owner ID <br /> Owner Name T&S GROUP <br /> Owner DBA <br /> Owner Address 902 CENTRAL AVE STE 5 <br /> TRACY, CA 95376 <br /> Home Phone 209-832-7000 <br /> Work/Business Phone Not Specified <br /> Mailing Address 902 CENTRAL AVE STE 5 <br /> TRACY, CA 95376 <br /> Care of T& S GROUP <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0007884 <br /> Facility Name SURLAND HOMES <br /> Location 2532 DORSET LN <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 APN: <br /> BOIS District 005-ORNELLAS, LEROY SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0014507 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CHEVRON ENVI NMENTAL MGMT CO (Circle One) <br /> Account Balance as of 10/11/2005: =70 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner' Delete <br /> SITE PR0508012 EE0000684-MICHAEL INFURNA Acti Y N A 1,2 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,antl/o reject specific,PHS/EHD hourly charges associated vnth this <br /> facility or activity vnll be billed to the party identified as the OWNER on this form. I also cartBy that all operations will be pertormetl in axorda ce vnth 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 Receiv dd <br /> REHS: Date_j�Q/__L�J_e2 Account out: Date RP K/ 126� <br /> COMMENTS: <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />