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Date run 8/4/2008 1:54:24PM SAN JOS 'N COUNTY ENVIRONMENTAL HEA' 7EPARTMENT Repon05021 <br /> Run byPaget <br /> Facility Information as of 81412OVIOW <br /> Record Selection Criteria: Facility ID FA0005626 <br /> Make changeslcorrections in RED Ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0004451 New Owner ID <br /> Owner Name SANBORN CHEVROLET INC <br /> Owner DBA SANBORN CHEVROLET INC <br /> Owner Address 1210 S CHEROKEE LN <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-334-5000 <br /> Mailing Address PO BOX 1057 <br /> LODI, CA 952411057 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0005626 <br /> Facility Name SANBORN CHEVROLET INC <br /> Location 1210 S CHEROKEE LN <br /> LODI, CA 95241 <br /> Phone 209-334-5000 <br /> Mailing Address PO BOX 1057 <br /> LODI, CA 952411057 <br /> Care of <br /> Location Code 02 -LODI Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 04728013 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SANBORN CHEVROLET INC <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0006259 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name SANBORN CHEVROLET INC (Circle One) <br /> Account Balance as of 8/4/2008: $0.00 <br /> (Circle One) <br /> Transfer to AcIwr,/1nectve <br /> PmgramlElemenl and Descnphon Record ID Employee ID and Name Status New Owner/ Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0505935 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO511429 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PR0519414 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0502946 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0507602 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0522805 EE5555555-Garrett Alias-Backus Active Y N A I D <br /> BILLING end 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 /> fadldy or activity will be billed to the party identified as this OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes andlor Standards and <br /> State andior Federal Lewis. <br /> APPLICANTS 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 _ Racal <br /> � ve ) <br /> RENS: l �✓// Date / / Account out: Date <br /> COMMENTS: <br /> Uphs-ehsgl-n tW pps\envision s\reports\5021.rpt <br />