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Date run 2/13/2014 11:34:35AI SAN J( WIN COUNTY ENVIRONMENTAL HEA 3 DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 2/13/2014 <br />Record Selection Criteria: Facility ID FA0017033 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0013874 <br />Owner Name <br />EC WATTS <br />Owner DBA <br />EC WATTS <br />Owner Address <br />17010 N LOCUST TREE RD <br />209-368-8606 x0 <br />LODI, CA 95240 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />-1-74-10-N--LOEU&T—TREE-RD <br />A I D <br />LODI, CA 95240 <br />Care of <br />A I D <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0017033 10,185,789 <br />Facility Name <br />EC WATTS <br />Location <br />17010 N LOCUST TREE RD <br />Program/Element and Description Record ID <br />LODI, CA 95240 <br />Phone <br />209-368-8606 x0 <br />Mailing Address <br />t7-0-1-0-N-1:OCUST-TREE RD <br />2220 - SM HW GEN <5 TONS/YR PR0536184 <br />LODI, CA 95240 <br />Care of <br />Location Code <br />BOS District <br />APN 05112036 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0029915 <br />Mail Invoices to Owner <br />Account Name EC WATTS <br />Account Balance as of 2/13/2014: $53.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID <br />1-1 � 3lv N l�c.us-� ► rcc Rc1 <br />17U3(o N L.oc t,��- 1 rcc �ci . <br />Alt Phone <br />Fax <br />EMail : <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />COMMENTS <br />(Circle One) <br />Transfer to <br />Active/Inactve <br />Program/Element and Description Record ID <br />Employee ID and Name Status New Owner? <br />Delete <br />1958 - HM -Farm Operations PRO525218 <br />Active Y N <br />A I D <br />2220 - SM HW GEN <5 TONS/YR PR0536184 <br />EE0001422 -ARTS CACAPIT Inactive Y N <br />A I D <br />2830 - AST FAC - SPCC EXEMPT PRO536185 <br />EE0001422 - ARIS CACAPIT Inactive Y N <br />A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0533342 <br />Inactive Y N <br />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 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: <br />Date <br />Program Records to be TRANSFERED: ' $25.00 = <br />Amount Paid Date <br />Water System to be TRANSFERED: <br />Amount Paid Date <br />Payment Type Check Number <br />Receivedy� <br />REHS: Date / <br />/ Account out: Date <br />COMMENTS <br />