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Date run 6/18/2015 10:58:08AI SA*AQUIN COUNTY ENVIRONMENTAL fe .TH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/18/2015 <br /> Record Selection Criteria: Facility ID <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: 0 SSN/Fed Tax ID <br /> Owner ID New Owner ID <br /> Owner Name <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID <br /> Facility Name <br /> Location <br /> Phone <br /> Mailing Address <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID New Account ID: <br /> Mail Invoices to Mail Invoices to: Owner / Facility / Account <br /> Account Name (Cirde One) <br /> (Circle One) <br /> Transfer to ActivellnacIve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. 1 also certify that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State and'or <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 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />