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Date run 7/2/2008 9:21:15AM SAN JOIN COUNTY ENVIRONMENTAL HEAJDEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 7/2/20G, <br /> Record Selection Criteria: Facility ID FA0012153 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0001165 New Owner ID <br /> Owner Name CITY OF STOCKTON <br /> Owner DBA <br /> Owner Address 305 N EL DORADO ST STE 200 _ <br /> STOCKTON, CA 95202 <br /> Home Phone 209-465-4528 <br /> Work/Business Phone 209-946-9222 pill 00 <br /> Mailing Address 22 E WEBER AVE#350 <br /> STOCKTON, CA 95202 <br /> Care of CITY OF STOCKTON <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012153 <br /> Facility Name SOUTH SHORE PARCEL <br /> Location WEBER AVE _ <br /> STOCKTON, CA 95202 <br /> Phone <br /> Mailing Address 22 E WEBER AVE #350 <br /> STOCKTON, CA 95202 <br /> Care of KITTY WALKER <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SUE BRAUSE <br /> Title PRINCIPAL ANALYST <br /> Day Phone 209-937-8840 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account lD A9� ,(� 1, I-Pi+7 New Account ID: <br /> Mail Invoices to Account CCOUnt Mail Invoices to: Owner / Facility / Account <br /> Account Name SOUTH SHORE PARCEL r' ¢ � r^9 (Circle One) <br /> Account Balance as of 7/2/2008: $0.00 <br /> (Circle One) <br /> Transfer to Active/InacNe <br /> Program/Element and Description Record ID Employee 10 and Name Status New Owner? Delete <br /> 2960-RWQCB SITE PR0515450 EE0009488- Active Y N A I D <br /> rrf.n (fir rarer <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledg that all site,antl/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity wit be billed to the party idenlfied as the OWNER on this form. I also certify that all operations unit be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State antllor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / / <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 —Recelvied byQ <br /> REHS: Date - / / Account out: Date4 / 2�1 OU <br /> COMMENTS: <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />