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Date run 8/7109 9:36:11AM <br /> Run by SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES Report #: 5023 <br /> Facility Information as of 817101 Page #: 1 <br /> Record Selection Criteria: Facility ID FA0012808 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br />{ OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> 1 Owner ID: OW0009982 New Owner ID. <br /> Owner Name: CITY OF STOCKTON-MUD <br /> I Owner DBA: <br /> Owner Address: 2500 NAVY DR <br /> STOCKTON, CA 95206 <br /> f Home Phone: 209-937-8718 <br /> j Work/Business Phone: Not Specified !� <br /> Mailing Address: 2500 NAVY DR �. <br /> STOCKTON, CA 95206 II <br /> Care of: <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0012808 <br /> Facility Name: CITY OF STOCKTON-MUD <br /> Location: BROOKSIDE & 15 <br /> STOCKTON, CA 95207 <br /> i Phone: 209-937-8322 <br /> Mailing Address: %TnK ) <br /> VY DR [�. �.M.' S o 1J.'V r <br /> QN, CA 95206 Of7 n p <br /> Care of: Sfi`QCKTON p p �Q <br /> I` Location Code: L APN:� , <br /> BOS District: SIC'Code: <br /> ACCOUNTS ECEIVABLE FILE INFORMATION <br /> • z <br /> Account ID: AR0021485 New Account ID: <br /> Mail Invoices to:�yty�' Mail Invoices to: Owner 1 Facili /Account <br /> Account Name: CITY OF -T�iQ=1�D (c cle One) <br /> Account Balance as of 817101: -319.90 <br /> (Circle One) <br /> Transfer to Activellnacive <br /> Program/Element and Description Record ID Employee ID and Name II Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PRO516793 EE0000694-MICHAEL INFURNA Active Y N A I D <br /> ,1 <br /> 'l <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that!all site,and/or project specific,PHSIEHD 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 Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> �I <br /> APPLICANT'S SIGNATURE: Date 1 I <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date <br /> Water System to be TRANSFERED! '$150.00= Amount Paid it Date / I <br /> Payment TyeCheck Number Rece/iv�ged, by <br /> RENS: Date_ I /�.Acoount out: l/f/ Date O 1 s7� I <br /> COMMENTS: <br /> i <br /> r <br /> i* IIPhs-ehsgl-ntlappslEnvisionslReports15021.rpt <br /> !� r <br />