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Date run 1/8/2014 1:55:57PM SAN JO JIN COUNTY ENVIRONMENTAL HEAR DEPARTMENT Report#5021 <br /> Pagel <br /> Run by �i+�'•- <br /> Facility Information as of 1/8/2014 <br /> Record Selection Criteria: Facility ID FA0019218 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSNI Fed Tax ID <br /> OwnerID OW0015531 New Owner ID <br /> Owner Name CITY OF LATHROP <br /> Owner DBA <br /> Owner Address 390 TOWNE CENTER DR <br /> LATHROP, CA 95330 <br /> Home Phone 209-941.7382 <br /> WoriJBusiness Phone 209-941-7380 <br /> Mailing Address 390 TOWNE CENTER DR <br /> LATHROP, CA 95330 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0019218 10187117 <br /> Facility Name LATHROP WELL#9 <br /> Location h t je 1,-j d c. QZ_ZA <br /> LATHROP, CA 95330 <br />{ Phone 209-941-7200 <br /> a <br /> F Mailing Address 390 TOWNE CENTER DR <br /> LATHROP, CA 95330 <br /> Care of CITY OF LATHROP <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 24131058 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> I Contact Name <br /> i <br /> l Title <br />+ Day Phone <br /> t Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> A <br /> Account ID A'R0034198 NewAccount ID: <br /> i Mail Invoices to Facility Mail Invoices to: Owner / Facility 1 Account <br /> Account Name LATHROP WELL#9 (CircfeOne) <br /> Account Balance as of 11812014: $0.00 <br /> (Circle One) <br /> Transfer to Aotivellnactve <br /> Program/Element and Description Record ID Employee ID and Name status New 01 Delete <br /> B - ns d N rk L ti 7. 0 - E I „Active Y N A I D <br /> '2840-AST EXEMPT FAC < 1,320 GAL PR0528589 EE0002646-THUY IRAN Active,/ Y N A I D <br /> t BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHSlEHD hourly charges associatedwith 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 /> r <br /> APPLICANT'S SIGNATURE: Date / 1 <br /> Program Records to be TRANSFERED: *$25.00 Amount Paid Date / 1 <br /> Water System to be TRANSFERED: Amount Paid Date / 1 <br /> j Payment Type Check Number Recei 90 OV <br /> 1 REHS: G'�' .,... Date _I_ 1 Account out: Dale I�iTI <br /> COMMENTS: <br /> i <br />