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Date run 9/30/2008 3:10:45PN SAN JO' 2UIN COUNTY ENVIRONMENTAL HE,'_ —H DEPARTMENT Report#5021 <br /> Run by — Pagel <br /> Facility Information as of 9/30/2uu8 <br /> Record Selection Criteria: Facility ID FA0019194 <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 FA0019194 <br /> Facility Name WESTSIDE INTERCEPTOR SANITARY STAT <br /> Locatio (0 4 b <br /> STOCKTON, CA 95206 <br /> Phone 209-937-8750 <br /> Mailing Address 2500 NAVY DR <br /> STOCKTON, CA 95206 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN 07114017 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 AR0034159 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name WESTSIDE INTERCEPTOR SANITARY STATI (Circle One) <br /> Account Balance as of 9/30/2008: $0.00 <br /> (Circle One) <br /> /N' Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee an Name ` Status New Owner? Delete <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATI\PR0528522 EE00 0753- ILLY NG Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or age o 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 <br /> REHS: Date / Account out: Date 1121_�! �S <br /> COMMENTS: <br /> \\ph s-eh sq I-n t\apps\envisions\reports\5021.rpt <br />