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Date run 9/26/2008 9:12:39AN SAN d% 7UIN COUNTY ENVIRONMENTAL HE?- -'•H DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/26/20u8 <br /> Record Selection Criteria: Facility ID FA0019197 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0012870 New Owner ID <br /> Owner Name COS MUNICIPAL UTILITIES DIST <br /> Owner DBA <br /> Owner Address 2500 NAVY DR <br /> STOCKTON, CA 95206 <br /> Home Phone 209-937-8708 <br /> Work/Business Phone Not Specified <br /> Mailing Address 2500 NAVY DR <br /> STOCKTON, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0019197 <br /> Facility Name MARCH LN/BUCKLEY COVE <br /> Locati C E- ?got t o W., L <br /> STOCKTON, CA 95206 <br /> Phone 209-937-8377 <br /> Mailing Address 2500 NAVY DR <br /> STOCKTON, CA 95206 <br /> Care of COS MUNICIPAL UTILITIES DIST <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 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 AR0034162 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name MARCH LN/BUCKLEY COVE (Circle One) <br /> Account Balance as of 9/26/2008: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATI\PR0528525 EE0004636-GARRETT BACKUS Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Receiv d <br /> RENS: Date / /U t Account out: Date <br /> COMMENTS: <br /> v �Yt �� (7L�(L,(�t� ViL"✓ <br /> \\phs-ehsq I-nt\apps\envisions\reports\5021.rpt <br />