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Date run 6/10/2015 10:55:06AI SAN JOAQUIN COUNTY ENVIRONMENTAL, HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 6/10/2015 Pagel <br /> Record Selection Criteria: Facility ID FA0022983 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: SSN 1 Fed Tax ID <br /> Owner ID OW0021010 New Owner ID <br /> Owner Name City Of Stockton MUD <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <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 ID I CERS ID FA0022983 10631755 <br /> Facility Name Storm Station Injection Site <br /> Location 3339 Perlman <br /> Stockton, CA 95205 <br /> Phone 209-937-8700 x <br /> Mailing Address 2500 Navy Dr. <br /> Stockton, CA 95206 <br /> Care of City Of Stockton MUD <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMaii. <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0042155 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner I Facility I Account <br /> Account Name City Of Stockton MUD (Circle One) <br /> Account Balance as of 611012015: : 0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgranvElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0540197 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENTI,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/i hourly charges associated with this facility <br /> or activity well be billed to the party identified as the OWNER on this form. I also certify that ali operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State ands <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE Date ! / <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date I / <br /> Water System to be TRANSFERED Amount Paid Date I I <br /> Payment Type Check Number Received by <br /> EHD Staff: %,A.r`J Date �I 1 1� 1 t' Account out: Date I I/ y/ <br /> COMMENTS: Invoice#: lob'p <br /> t,t T-1 4- ( o-1 lLAtv� <br /> 1 Lt� L G F�ey"-- <br />