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Date un 7/15/2013 12:50:14PI SAN JONv/1IN COUNTY ENVIRONMENTAL HEM"..41IDEPARTMENT Report 95021 <br /> Paget <br /> Ron by Facility Information as of 7/15/2013 <br /> Racord Selection Criteria: Facility ID FA0010236 <br /> Make changesicorrections in RED"nk. <br /> INFORMATION CHANGE(date) 7 1 Com_ <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID : <br /> Owner ID -G*JGGg82.3& Case Number: H07431 New Owner ID : � <br /> Owner Name 4g pAJGE—JR <br /> Owner DBA tfT- <br /> OwnerAddress 4H{d-$fl�CftAME1. p{Ta$ <br /> n r nn <br /> Home Phone Not Specified <br /> Work/Business Phone 2GG3t3--S'�te <br /> Mailing Address <br /> I nDl Q+24D <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0010236 <br /> rc <br /> Facility Name Q M� 1 <br /> Location 103 E ELM ST <br /> LODI, CA 95240 <br /> Phone 209-333-639U <br /> Mailing Address 294 �/OZ AA S� <br /> LODI, CA 95240 <br /> Care of <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -VOGEL, KEN - Fax <br /> APN 04308406 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017236 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name LAKEWOOD AUTO REPAIR (Circle One) <br /> Account Balance as of 7/15/2013: $0.00 <br /> P l 2A� C�`AW 11;'17, <br /> A 7, I 44 <br /> )0 2,y 4` . 1 /� i ,�(J NI /J (Circle One) <br /> a• I err t vu 1" !� L�(/ rl ��/ Transfer to P.aiva'Inactve <br /> Rrarn✓Elemenl and Description Record ID Employee ID and Name Status New Ovmer? Delete <br /> HMBP-Regular-Primary Location PR0520178 EE0008709-JAMIE DE LA ROSA Inactive Y NJ I D <br /> SM HW GEN<5 TONSNR PRO514242 EE0001422-ARTS CACAPIT Inactive Y NI D <br /> HAZ MAT BUSINESS PLAN AUTHORIZATION PRO512524 EE0000o00-HAZ MAT SJC OES Inactive Y N I D <br /> 2226-CaIARP PROGRAM PRO514748 EEO0000o0-HAZ MAT SJC OES Inactive Y N A I D <br /> 2245-PACT TRANSFER RECORD-SUPPLEMENTAL PRO629750 EE0008709-JAMIE DE LA ROSA Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510236 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 4740 WASTE TIRE SITE-EXEMPT PR0526414 EE0002622-BENJAMIN ESCOTTO Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532618 Inactive 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 facility <br /> or activity will be billed to the party identified as the OWNER on this form I also certify that all operations wiil be performed in accordance with all applicable Ordinaries Codes and/or Standards and State andror <br /> Federal Laws. <br /> atm p k e"Aw Pr 272-1iD 2X( a�ao q <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Ty Check Number Rem <br /> REHS: - t r61V ��C� Date—:!?--/ S/ Account out: Date / 12_/ 63 <br /> COMMENTS: <br />