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San Joa uin CountyPHS/EHD Report #5021 <br /> Run byf LAURIEB 4 <br /> FACILITY INFORMATION as of 07/21/99 <br /> ------- --- - - - - - - -- - - ---------------------------------------- <br /> Make changes/corrections in RED pen or pencil: <br /> OWNER FILE INFORMATION INFORMATION CHANGE (date) : <br /> OWNERSHIP CHANGE (date) : <br /> OWNER ID: 008653 CASE # : H08467 New Owner ID: 00 <br /> Owner Name: CITY OF STOCKTON- MUD <br /> Owner DHA: <br /> Owner Address: <br /> Home Phone: ' <br /> Soc Sec# / Tax ID#: <br /> Ownership Type: 04 LOCAL—AGENCY <br /> Mailing Address: 2500 NAVY DRIVE <br /> Care of: <br /> STOCKTON, CA 95206 <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 010653 <br /> Facility Name: STKN MUD WELLS - PRIMARY <br /> Location: 7604 BRENTWOOD DR <br /> STOCKTON 95207- 20 <br /> Phone: 209-937-8730 <br /> Mailing Address: 2500 NAVY DR <br /> Care of: MORRIS L ALLEN <br /> STOCKTON, CA 95206 <br /> Location Code: 01 APN: 121-180-32 <br /> BOB District: 002 SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0017653 New Account ID: 000 <br /> Mail Invoices to: Account Mail Invoices to: Owner / Facility / Account <br /> Account Name: STKN MUD (Circle one) <br /> Account Balance as of 07/21/99 : $100 . 00 (Circle one) <br /> Record UST(a) Transfer to Activate / Inactivate <br /> P/E Description ID Employee Status Linked new owner? Delete <br /> ------------------------------------------------------------------------------- <br /> 2399 UNIFIED PROGRAM FAC STATE SERV PR510653 0000 SJC USE ACTIVE Y N A I D <br /> 2224 HAZ MAT BUSINESS PLAN AUTHORIZ PR512941 0000 SSC OES ACTIVE Y N A CD <br /> 2220 SM EW GEN c5 TONS/YR PR514396 0418 KITH ACTIVE YA NA �.II Q D- <br /> al <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. I also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> ------------------------------- - ----------------------------------------------- <br /> PR Records to be TRANSFERED: x $20.00 Amount Paid Date_/ / <br /> Water System to be TRANSFERED: x $150.00 = Amount Paid Date / <br /> Payment Type Check # Recvd by <br /> ---- -----,-'-A-� --------------------------------- ----t------------------------ <br /> REHS or COUNTER SUPV: y/�' Date/ /�_ ACCT out: Date O ( /07 / UNIT/File:_/_/_ <br />