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Date nin 7/7/200810:21:15AM SAN Jr ,JIN COUNTY ENVIRONMENTAL HEi, DEPARTMENT Report 95021 <br /> Pagel <br /> Rim by <br /> Facility Information as of 7/7/200$' <br /> Record Selection Cnieria. Fauhty ID FA0005626 <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 lD OW0004451 New Owner I <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 Entail: <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 I Facility / Account <br /> Account Name SANBORN CHEVROLET INC (cir,zleOhe) <br /> Account Balance as of 7/7/2008: $0.00 <br /> (Circle 0.) <br /> Transfer to Adnellnadve <br /> Program/Element and Description Record 10 Employee 10 and Name Status Naw Ownef+ 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 EE0000o00-HAZ MAT SJC DES Active Y N A I D <br /> 2351 -UST FACILITY(BEFORE 1/84)-obsolete PRO502946 EE0004636-GARRETT BACKUS Inactive Y N A 1 D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARFIR0507602 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 and COMPLIANCE ACKNOWLEDGEMENT: I,the undemgned owneroperator a agent of same,acAnowledge that all aft,andrar pro)ecit specific,PHS/EHD hoary ciwrgea associateo cabin this <br /> facility or wMdy will Pa billed to the party Identified as the OWNER on Ws W. I also certify that all operations will he performed In BCCOIdarice with ad applicable Ord,nace Codes andlor Standards am <br /> State anwor Federal laws. <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—J / <br /> Payment Type Check Number Received by <br /> REHS: Date_J l Account out: Date 1 / <br /> COMMENTS: <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />