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Date run 8/6/2012 12:03:09PM SAN JO44woUIN COUNTY ENVIRONMENTAL HEAT DEPARTMENT Report 95021 <br /> Run by Pagel <br /> Facility Information as of 8/6/2012 <br /> Record Selection Criteria: Facility ID FA0010682 <br /> Make changesfcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN!Fed Tax ID <br /> Owner ID OW0008643 New Owner ID <br /> Owner Name CITY OF STOCKTON- MUD <br /> Owner DBA <br /> Owner Address 2516 NAVY DR <br /> STOCKTON, CA 95206 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-937-8246 <br /> Mailing Address 2500 NAVY DR <br /> STOCKTON, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010682 <br /> Facility Name STKN MUD WELLS#SSS-5 <br /> Location 6 —VVAY <br /> STOCKTON, CA 95206 <br /> Phone <br /> Mailing Address 2500 NAVY DRIVE <br /> STOCKTON, CA 95206 <br /> Care of <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 17726026 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 AR0017682 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner ! Facility I Account <br /> Account Name STKN MUD (Circle One) <br /> Account Balance as of 81612012: $0.00 <br /> (Circle One) <br /> Transfer to Activannactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOfPR0512970 EE0000000-HAZ MAT SJC OES Inactive Y N A 1 D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PRO510682 EE00o0000-HAZ MAT SJC OES inactive Y N A I D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PRO528501 EE0002670-MUNIAPPA NAIDU Active,Exempt Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT, I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSIEHD 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 andlor Standards and State and'or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I ! <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 ! <br /> Water System to be TRANSFERED: Amount Paid Date 1 ! <br /> Payment Type Check Number Receivzy; <br /> REHS: Date 1 1 Account out: (�f� Date I reZ <br /> COMMENTS: <br />