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Date run 12/23/2011 1:20:45P SAN JC -NUIN COUNTY ENVIRONMENTAL HEA'—q DEPARTMENT Report#5021 Run by Pagel Facility Information as of 12/23/21, Record Selection Criteria: Facility ID FA0017033 OWNER FILE INFORMATION \ Owner ID OW0013874 EC WATTS Owner Name EC WATTS Employee ID and Name Status New Owner? Owner DBA EC WATTS 209-368-8606 x0 Owner Address 17010 N LOCUST TREE RD LODI, CA 95240 LODI, CA 95240 WATTS, KEITH Home Phone Not Specified BOS District Work/Business Phone Not Specified 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 Mailing Address 17010 N LOCUST TREE RD Title LODI, CA 95240 Day Phone Care of Night Phone FACILITY FILE INFORMATION Facility ID FA0017033 Facility Name EC WATTS Location 17010 N LOCUST TREE RD Employee ID and Name Status New Owner? LODI, CA 95240 Phone 209-368-8606 x0 Mailing Address 1051 LINCOLN AVE Active Y N LODI, CA 95240 Care of WATTS, KEITH Location Code ERSC - ELECTRONIC REPORTING STATE SURCHPR0533342 BOS District A I D APN 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 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Date Day Phone Program Records to be TRANSFERED: ' $25.00 = Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0029915 Mail Invoices to Facility Account Name EC WATTS Account Balance as of 12/23/2011: $0.00 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail New Account ID: : Mail Invoices to: Owner / Facility / Account (Circle One) \\eh-env\envision\reports\5021. rpt (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 2220 - SM HW GEN <5 TONS/YR PRO536184 EE0001422 - ARIS CACAPIT Active Y N A 1 D 2223 - AGRICULTURAL HAZ MAT STORAGE FACILPRO525218 Active Y N A I D 2830 - AST FAC - SPCC EXEMPT PR0536185 EE0001422 - ARIS CACAPIT Active,Exempt Y N A 0 D ERSC - ELECTRONIC REPORTING STATE SURCHPR0533342 Active Y N A I D 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 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 State and/or Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Rec ' by REHS: Date'I_ Account out: Date COMMENTS: \\eh-env\envision\reports\5021. rpt