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Date run 11/9/2011 1:47:58PN SAN,Ir ' N COUNTY ENVIRONMENTAL HEALT" "'?PARTMENT Report#5021 <br /> -OUI <br /> Run by 4006 Pagel <br /> Facility Information as of 11/9/2011 <br /> Record Selection Criteria: Facility ID FA0012222 <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 OW0009477 New Owner ID <br /> Owner Name CORDES, DAVE <br /> Owner DBA CORDES FARM <br /> Owner Address 24915 S HANSEN RD':. <br /> TRACY, CA 95376 <br /> Home Phone 209-835-5533 <br /> Work/Business Phone 209-835-5533 <br /> Mailing Address 24915 S HANSEN RD <br /> TRACY, CA 95376 <br /> Care of DAVE CORDES <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012222 <br /> Facility Name CORDES FARM <br /> Location 24915 S HANSEN RD <br /> TRACY, CA 95376 <br /> Phone 209-835-5533 <br /> Mailing Address 1 SUTTER ST <br /> SAN FRANCISCO, CA 94104 <br /> Care of ALL WEST ENVIRONMENTAL <br /> Location Code 03-TRACY Alt Phone <br /> BOS District 005- ORNELLAS, LEROY Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name ALL WEST ENVIRONMENTAL <br /> Title <br /> Day Phone 209-835-5533 <br /> Night Phone 209-835-5533 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0019712 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name CORDES FARM (Circle One) <br /> Account Balance as of 11/9/2011: $0.00 <br /> (Circle One) <br /> Transfer to Active/ actve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? el to <br /> 2950-ENVIRON ASSESS PR0515532 EE0000756-CAROLOZ A Y N A ' 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,a d/or project specific,PHS/EHD hourly charges asso with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I 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: '$25.00= Amount Paid Date <br /> Water System to N ERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> RENS: Date / / Account out: ate I/ <br /> COMMENTS: <br /> r <br /> SG�J�✓ <br /> \\e h-env\envision\reports\5021.rpt <br />