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Date run 8/6/2012 12:01:38PM SAN 301 TIN COUNTY ENVIRONMENTAL HEAIr DEPARTMENT Report*5021 <br /> Run by *1111NO, Paget <br /> Facility Information as of 8/6/2012 <br /> Record Selection Crtteria: Facility ID FAD010681 <br /> Make changestcorrections 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 FA0010681 <br /> Facility Name STKN MUD WELLS#SSS-4 <br /> Location 71$ Y —7JoO- $ "4L 51` <br /> STOCKTON, CA 95206 <br /> Phone <br /> Mailing Address 2500 NAVY DRIVE <br /> STOCKTON, CA 95206 <br /> Care of <br /> Location Cade 99- UNINCORPORATED p Alt Phone <br /> Bos District 001 -VILLAPUDUA Fax <br /> APN 17726024 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 AR0017681 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner 1 Facility / Account <br /> Account Name STKN MUD (Circle one) <br /> Account Balance as of 81612012: $0.00 <br /> (Circle One) <br /> Transfer to ActiveAnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOPPRO512969 EEOOOOOOO-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0510681 EEOOOOOOO-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PRO626499 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 hourlycharges 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 aocordance with all applicebte Ordinance Codes andfor Standards and State andror <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / 1 <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date I 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 I <br /> Payment Type Check Number Received¢y <br /> REHS: Date 1 I Account out: 4( Date E/ (,o //2— <br /> COMMENTS: <br /> CQMMENTS: 1 <br />