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Dale run 10/2/2014 9:23:42Ah SAN.�QUIN COUNTY ENVIRONMENTAL HE `'H DEPARTMENT ReportOW21 <br /> Run by �/ Pagel <br /> Facility Information as of 10/2/2014 <br /> Record Selection Criteria: Facility iD FA0019194 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 9 SSN/Fed Tax ID <br /> Owner ID OW0012870 New Owner ID <br /> Owner Name CITY OF STOCKTON -MUD <br /> Owner DBA <br /> Owner Address 2500 NAVY DR <br /> STOCKTON, CA 95206 <br /> Home Phone 209-937-8708 <br /> Work/Business Phone 209-937-8700 <br /> Mailing Address 2500 NAVY DR <br /> STOCKTON, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0019194 10187091 <br /> Facility Name WESTSIDE INTERCEPTOR SANITARY STA- <br /> Location 6461 BROOKSIDE RD <br /> STOCKTON, CA 95206 <br /> Phone 209-937-8750 x <br /> Mailing Address 2500 NAVY DR <br /> STOCKTON, CA 95206 <br /> Care of CITY OF STOCKTON-MUD <br /> Location Code Alt Phone <br /> BOIS District Fax <br /> APN 07114017 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0034159 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name WESTSIDE INTERCEPTOR SANITARY STATI tcircleOne) <br /> Account Balance as of 10/2/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/Ini <br /> ProgramfElement and Description Record ID Employee ID and Name Status New Owner, Delete <br /> 1920-HMBP-Common Materials PRO539206 EE0000006-HAZA SAEED Active Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PRO528522 EE0000005-FATINAH ZAREEF Active,l Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532477 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anHor project specific,P S1EHD hourlycharges associatedwith thisfacility <br /> or activity will be billed to me party identified as the OWNER on this form. I also candy that all operations will be performed in accordance with all applicable Ordinance Codes anclor Standards and State andfor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date_/_I <br /> Payment Type Check Number Received by <br /> REHS: Date_/ I Account out: Date_/ / <br /> COMMENTS: <br />