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Form 1 IDE gan Deparment Rov. 205 SERMCE Nay Oo STATUS REPORT FOR AGENCY USE ONLY Po.sorssess Ste yn erescoss READ INSTRUCTIONS ON REVERSE SIDE THEN COMPLETE ALL ITEMS 35/0 (TYPE OR PRINT LEGIBLY) a = Ind. 1. Type of ownership: Cr individual Oi Partnership BH Corporatio ‘Type. eff | 2 Corporation, trade, or business name, and mailing address for quarterly contribution (tax) Se reports: Inactive Aqua Systems, Inc. 469 S. Parkside Circle \ S.County in Ulan __|6. Number a per- St. George, UT 84770 | "where principal actviy|” manent work | | locates Shes m Uta bees | 3. Telephone Number: ( 435) 652-3908 Washington x 7, Maling address for Wage and Separation] 6 Steel address of principal permanent work | 9. Steet Address of business neaduarters Requests i iferent tom tem 2) site in Utah (tditferent rom fem 27 or 9} |i ifrent rom tom 2 | | | | | | | 70. List sole proprietor, general partners, corporate officers, or imited labiliy company members: Name Social Sec. # Title Home Address: Home Phone St. George, UT 84770 11. Describe in detal the specific product or service you provide in Utah. 72. lfyou are a new business in Utah, | ‘show date business started. | Commercial and residential water treatment sales and service READ INSTRUCTIONS ON THE REVERSE SIDE BEFORE COMPLETING ANY ITEMS IN #14 10/1/97 14, Did you acquire the organization, rade, or business of another operator? 0 Yes & No Type of acquisition: C Change in form of ownership 1 Merger or reorganization 1 Sale, lease or sub-lease 0 Purchased assets through court (i Other, please explain 13. Date of first payment of wages in Utah 11/15/97 ‘4a, Name, address and account number i available) of previous operator (predecessor * Date acquired "4b. tyou acquiredall ora portion ofthe predecessor's organization, trade orbusiness pleaseindicate: [] All [) s0%ormore [1] Lesstnanso%4 ‘14c. Did you retain all of the predecessor's employees? Yes [No 14d. Is your predecessor silin business? C] Yes] No 14e. Was predecessor's business closed prior acquisition? C] Yes] No _Date closed Tis: Enter the amount of wages you have paid in Utah below. f you have not paid wages enter “NONE | Jan. 1 to March 31 April 1 to June 30 July 1to Sept.30 | Oct. 1 10 Dec. 31 Curent Year None None None None Precedi veer None None None I “None 16. it you have not paid wages, do you expect to in the future? GJ Yes [] No Show estimated date 11/15/97 _ Ie t contained inthis report is true and correct. - x ae President (435) 652-3908 js tae Tite Teuphore Member Osis