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Date run 12/24/2014 1:17:28P SAN JOOUIN COUNTY ENVIRONMENTAL HEA*DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/24/2014 <br /> Record Selection Criteria: Facility ID FA0013570 <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: 2 SSN/Fed Tax ID : <br /> Owner ID OW0010691 New Owner ID <br /> Owner Name RIPON, CITY OF <br /> Owner DBA PUBLIC WORKS WELL#3 <br /> Owner Address 1210 S VERA AVE <br /> RIPON, CA 95366 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-599-2108 <br /> Mailing Address 1210 S VERA AVE <br /> RIPON, CA 95366 <br /> Care of TED JOHNSTON <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0013570 10184417 <br /> Facility Name PUBLIC WORKS WELL#3 <br /> Location 922 SECOND ST <br /> RIPON, CA 95366 <br /> Phone 209-599-2151 x <br /> Mailing Address 1210 S VERA AVE ;a 5q /U. W, Irma. 4/-&— <br /> RIPON, CA 95366 ng t bj r[j q ri (a 42 <br /> Care of City of Ripon <br /> Location Code 05- RIPON Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 25917003 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name TED JOHNSTON <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022679 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name PUBLIC WORKS WELL#3 (Circle One) <br /> Account Balance as of 12/24/2014: $0.00 <br /> (Circle One) <br /> Transfer to Activelinaclve <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1926-HMBP-Unstaffed Network Location PR0517731 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0517730 EE0009903-DOUG WILSON Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor proled 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. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <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 TyP� Check Number Receivgd�y <br /> REH' Date�/2/ Account out: (i1,'� \Date <br /> COMMENTS. <br />