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Date run 1/8/2014 1:55:57PM SAN J IN COUNTY ENVIRONMENTAL HEAJ*DEPARTMENT Report 05021 <br /> Run by Pagel <br /> Facility Information as of 1/8/2014 <br /> Record Selection Catena: Facility ID FA0019218 <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 OW0015531 New Owner ID <br /> Owner Name CITY OF LATHROP <br /> Owner DBA <br /> Owner Address 390 TOWNE CENTER DR <br /> LATHROP, CA 95330 <br /> Home Phone 209-941-7382 <br /> Work/BusinessPhone 209-941-7380 <br /> Mailing Address 390 TOWNE CENTER DR <br /> LATHROP, CA 95330 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0019218 10187117 <br /> Facility Name LATHROP WELL#9 <br /> Location i -] 5(6 L Q 1 r7 e— <br /> LATHROP, CA 95330 <br /> Phone 209-941-7200 <br /> Mailing Address 390 TOWNE CENTER DR <br /> LATHROP, CA 95330 <br /> Care of CITY OF LATHROP <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 24131058 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 AR0034198 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name LATHROP WELL#9 (Circle One) <br /> Account Balance as of 1/8/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/InacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Omen Delete <br /> 1926-HMBP-Unstaffed Network Location PR0537i95 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PR0528589 EE0002646-THUY TRAN Active,l Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of some,acknowledge that all site,andor project specific,PHBEHD 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 anNor 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 Recel <br /> RENS: Date_ / ;ii—l / _ Account out: Date <br /> COMMENTS: <br />