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Date run 8/6/2012 11:66:05AM SAN dO ,JIN COUNTY ENVIRONMENTAL HEAL I DEPARTMENT Report#M21�" Paget <br /> Run by Facility Information as of 8/6/2012 <br /> Record Selection Criteria: Facility ID FAGO10668 " <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN I 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 FA0010668 <br /> Facility Name STKN MUD WELLS#16 <br /> Location g 1 1rifi re$ <br /> STOCKTON, CA 95210 <br /> Phone <br /> Mailing Address 2500 NAVY DRIVE <br /> STOCKTON, CA 95206 <br /> Care of <br /> Location Code Alt Phone <br /> BIDS District Fax <br /> APN 07228027 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 AR0017668 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name STKN MUD (Circle One) <br /> Account Balance as of 81612012: $0.00 <br /> (Circle One) <br /> Transfer to Activeftna¢tve <br /> Prograrn/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1926-HMBP-Unstaffed Network Location PRO512956 EE0009817-ROBERT LOPEZ Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0510668 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PRO528515 EE0004636-GARRETT BACKUS 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,andtor project specific,PHSIEHD hourly charges associated with this faality <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 andror Standards and State ani <br /> Federal laws. <br /> APPLICANT'S SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: '$25.00 Amount Paid Date 1 I <br /> Water System to be TRANSFERED: Amount Paid Date 1 I <br /> Payment Type Check Number Received by <br /> REHS: Date 1 I Account out: D5 Date 1�_I <br /> COMMENTS: V 6-j � r ' <br /> P d I //Lip ` � <br />