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Runby : STAFF San Joaquin County PHS/EHD Report #5021 FACILITY INFORMATION as of 02/01/96 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Make changes/corrections in RED pen or pencil: OWNER FILE INFORMATION INFORMATION CHANGE (date): OWNERSHIP CHANGE (date): OWNER ID: 002199 New Owner ID: 00 Owner Name: DELTA WETLANDS Owner DBA: DELTA WETLANDS CAMP #99 Owner Address: 3697 MT DIABLO BLVD #320 LAFAYETTE, CA 94549 Hame Phone: Work/Business Phone: 510-283-4216 Maiting Address: 3697 MT DIABLO BLVD #320 care of: KYSER FARMS LAFAYETTE, CA 94549 FACILITY FILE INFORMATION FACILITY ID: 002946 Facility Name: BACON ISLAND CAMP #3 Location: 1 MI W/BAC ISL RD, 1 . 7MI NW/MR STOCKTON 95206 Phone: 209-464-7979 Mailing Address: PO BOX 343 care of: KYSER FARMS STOCKTON, CA 95201 Location Code: 9 9 APN: BOS District: 003 SIC Code: ACCOUNTS RECEIVABLE FILE INFORMATION ACCOUNT ID: 0002508 New Account ID: 000 Mail Invoices to: Facility Mail Invoices to: Owner / Facility / Account Account Name: BACON ISLAND CAMP #3 (Circle one) Account Balance as of 02/01/96 : $0 . 00 (Circle one) Record UST(s) Transfer to Activate / Inactivate P/E Description ID Employee Status Linked new owner? Delete - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 2755 EMPLOYEE HOUSING PR270099 0626 CASTRO ACTIVE Y N A I D - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this form. 1 also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PR Records to be TRANSFERED: x $20.00 Amount Paid Date_/—/— Water /Water System to be TRANSFERED: x $150.00 = Amount Paid Date_/ / Payment Type Check # Recvd by REHS or COUNTER SUPV — Date—/—/— ACCT out Date—/_/ UNIT/File:_/_/ Runby : STAFF San Joaquin County PHS/EHD Report #5021 6 FACILITY INFORMATION as of 02/01/96 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Make changes/corrections in RED pen or pencil: