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114 <br /> Date run <br /> Run by 11/13/2014 9:33:13A SAN JC UIN COUNTY ENVIRONMENTAL HEA ' DEPARTMENT Report#5021 <br /> Pagel <br /> Facility Information as of 11/13/2014 <br /> Record Selection Criteria: Facility ID FA0021386 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 72 SSN/Fed Tax ID <br /> Owner ID OW0008643 New Owner ID <br /> Owner Name CITY OF STOCKTON- MUD <br /> Owner DBA <br /> Owner Address 2500 NAVY DR <br /> STOCKTON, CA 95206 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-937-8700 <br /> Mailing Address 2500 NAVY DR <br /> STOCKTON, CA 95206 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021386 10187851 <br /> Facility Name STOCKTON MUD WELLS-BUCKLEY COVE <br /> Location 0 MARCH LN @ BUCKLEY COVE <br /> STOCKTON, CA 95219 <br /> Phone 209-937-8246 x <br /> Mailing Address 2500 NAVY DR <br /> STOCKTON, CA 95206 <br /> Care of CITY OF STOCKTON- MUD <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN 11603002 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 AR0038751 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name STOCKTON MUD WELLS-BUCKLEY COVE (Circle One) <br /> Account Balance as of 11/13/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1926-HMBP-Unstaffed Network Location PR0537259 EE0000006-HAZA SAEED Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,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 accordance with all applicable Ordinance Codes and/or 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 Recei <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />