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Date run 6/30/2009 12:02:13PI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/30/2009 <br /> Record Selection Criteria: Facility ID FA0016343 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> SSN/Fed Tax ID <br /> Owner ID OW0013222 '� New Owner ID <br /> Owner Name EAST BAY MUD <br /> Owner DBA EBMUD <br /> Owner Address 2000 CAMANCHE RD <br /> ZONE, CA 95640 <br /> Home Phone 209-763-5121 <br /> Work/Business Phone Not Specified <br /> Mailing Address 2000 CAMANCHE RD <br /> ZONE, CA 95640 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0016343 <br /> Facility Name EBMUD <br /> Location 25724 MCINTIRE <br /> CLEMENTS, CA 95227 <br /> Phone <br /> Mailing Address 25724 MCINTIRE <br /> CLEMENTS, CA 95227 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 02301001 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION 0-r� <br /> Account ID AR0028624 �� New Account ID: <br /> Mail Invoices to Account hj Mail Invoices to: Owner / Facility / Account <br /> Account Name PC EXPLORATION �C.� ,meg, (Circle One) <br /> Account Balance as of 6/30/2009: $-5.00 U <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0524361 EE0000997-HARLIN KNOLL 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/EHD 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. t� I— <br /> APPLICANT'S SIGNATURE: e e C>�� a Date 0 / 30 <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Received bY <br /> REHS: Date / / Account out: Date 10/ Q C1 <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />