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Date run 8/1/2011 2:15:29PM SAN JC WIN COUNTY ENVIRONMENTAL HEA' —H DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 8/1/201 , <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 />LODI, CA 95240 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />17010 N LOCUST TREE RD <br />LODI, CA 95240 <br />Care of <br />FACILITY FILE INFORMATION <br />FacilityID FA0017033 <br />Facility Name EC WATTS <br />Location 17010 N LOCUST TREE RD <br />LODI, CA 95240 <br />Phone 209-368-8606 x0 <br />Mailing Address 17010 N LOCUST TREE RD <br />LODI, CA 95240 <br />Care of <br />Location Code <br />BOS District <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <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 />W4,61 At. <br />ACCOUNTS RECEIVABLE FILE INFORMATION ' �1 co [ L � <br />Account ID AR0029915 I New Account ID: <br />Mail Invoices to Owner}Jy% US 1 g Mail Invoices to: Owner / Facility / Account <br />Account Name EC WATTS Tl }J` - pet')A �,� � `EyL i � o o (Circle One) <br />Account Balance as of 8/1/2011: $426.00 QfNi(/(� <br />U j <br />Lloy <br />r' \ ltil (Circle One) <br />ansfer to Active/InacNe <br />Program/Element and Description Record ID eeI( ID and Name O Status I I ,Qj L , I� New Owner? Delete <br />2220 - SM HW GEN <5 TONSNR PR0536184 EE0001422 - ARIS CACAPIT Active l� Y N A I D <br />2223 - AGRICULTURAL HAZ MAT STORAGE FACILPRO525218 Active Y N A I D <br />2830 - AST FAC - SPCC EXEMPT PR0536185 EE0001422 - ARIS CACAPIT Active,Exempt Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHPR0533342 Active Y N 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/EFID 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: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: <br />COMMENTS: <br />\\eh-env\envision\reports\5021. rpt <br />* $25.00 = <br />Date <br />Date / <br />Amount Paid Date <br />_ Amount Paid Date <br />Recely <br />Account out: Date 6�2/17 <br />