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Date run 1/14/2013 8:59:49AK SANJUIN COUNTY ENVIRONMENTAL HEAjW DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1/14/2013 <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 SSN/Fed Tax ID <br /> Owner ID OW0010691 New Owner 10 <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 Not Specified <br /> Mailing Address 1210 S VERA AVE <br /> RIPON, CA 95366 <br /> Care of TEDJOHNSTON <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013570 <br /> Facility Name PUBLIC WORKS WELL#3 <br /> Location 922 SECOND ST <br /> RIPON, CA 95366 <br /> Phone 000-000-0000 "" <br /> Mailing Address 2� ti <br /> / hii t- <br /> I On/ — to Co <br /> Care of TEDJOHNSTON <br /> Location Code 05-RIPON Alt Phone <br /> BOS District Fax <br /> APN 25917003 EMail: <br /> ORGENCY 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 NewAccount ID: <br /> Maillnvoicesto Facility Maillnvoicesto: Owner / Facility / Account <br /> Account Name PUBLIC WORKS WELL#3 (Circle One) <br /> Account Balance as of 1/14/2013: $0.00 <br /> (Circe One) <br /> Transfer to ActiveAnactme <br /> Pr raMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1926 MBP-Unstaffed Network Location PRO517731 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 9-UNIFIED PROGRAM FAC STATE SURCHAR(PR0517730 EE0009903-DOUG WILSON Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned owner,operator or agent ofsame,acknowledge that all site,and'or project spetlric,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 accomance with all applicable Ordinance Codes andror Standards and State andor <br /> Federal Laws. <br /> APPLICANTS 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 b r <br /> REHS: - Date eo / may �-- <br /> / 3 Account out: — Date <br /> aE <br />