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Date run 11/22/2013 9:13:23A SAN JO iIN COUNTY ENVIRONMENTAL HEA1 DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 11/22/2013 <br /> Record Selection Criteria: Facility ID FA0021137 <br /> Make changes/corrections in RED ink. �J <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0017412 New Owner ID <br /> Owner Name LYON, THOMAS S <br /> Owner DBA <br /> Owner Address 301 W KETTLEMAN LN <br /> LODI, CA 95240 <br /> Home Phone 530-400-2613 <br /> Work/Business Phone 209-368-9779 <br /> Mailing Address 301 W KETTLEMAN LN <br /> LODI, CA 95240 <br /> Care of LYON, THOMAS S <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021137 10,187,759 <br /> Facility Name OILSTOP <br /> Location 301 W KETTLEMAN LN <br /> LODI, CA 95240 <br /> Phone 209-368-9779 <br /> Mailing Address 301 W KETTLEMAN LN <br /> LODI, CA 95240 <br /> Care of LYON, THOMAS S <br /> Location Code Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 04514002 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 AR0038120 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name OILSTOP (Circle One) <br /> Account Balance as of 11/22/2013: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PR0536822 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 4 GEN 25<50 TONS PERMIT PR0536804 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 32- XEMPT TANK FACILITY PR0535303 EE0001422-ARIS CACAPIT Active,I Y N A (F7 D <br /> ELECTRONIC REPORTING STATE SURCHARG PR0536805 Inactive Y N A `� D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andior project specific,PHS/EHD hourly charges associated with this facility or; <br /> be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State and/or Federal Laws. <br /> C,vI ,l ?rel1� <br /> APPLICANT'S SI NATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Typ Check Number Receiv <br /> REHS: i �L�� ,�, Date�I / ( /" l Account out: Date <br /> COMMENTS: ^�� '1� I (� �"V```� �� �\/ 1 � �� � v �I��" �✓�Q(/��-�/' <br />