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Date run 4/2,9/2008 9:28:11AK SAN JO -JIN COUNTY ENVIRONMENTAL HEA 4 IEPARTMENT Report #5021 <br />Run b�+ Pagel <br />Facility Information as of 4/29/2008 <br />Record Selection Criteria: Facility ID FA0007953 <br />"L-CA <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0005795 <br />Owner Name <br />CHEVRON USA PRODUCTS CO <br />Owner DBA <br />CHEVRON STATION <br />Owner Address <br />6001 BOLLINGER CANYON RD <br />Phone <br />SAN RAMON, CA 94583 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />925-842-9002 <br />Mailing Address PO BOX 6003 <br />SAN RAMON, CA 94583 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0007953 <br />Facility Name <br />CHEVRON #9-5775 <br />Location <br />301 KETTLEMAN LN <br />LODI, CA 95240 <br />Phone <br />Mailing Address 301 KETTLEMAN LN <br />LODI, CA 95240 <br />Care of <br />Location Code <br />BOS District 004 - VOGEL, KEN <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />cis <br />Account ID AR0014731 - <br />Mail Invoices to Account QHS <br />Account Name ARCADIS U S INC- C <br />Account Balance as of 4/29/2008: $196.00 <br />Make changes/corrections in RED ink or pencil. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />New Owner ID : <br />APN:04514002 <br />SIC Code: <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inaclve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />2957 - UST FILE - RWQCB PR0508132 EE0000997 - HARLIN KNOLL Active 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 <br />facility or activity will 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 Ordinace Codes and/or Standards and <br />Slate and/or Federal Laws. <br />APPLICANT'S SIGNATURE: �� ` I" -4�u 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 Received by <br />REHS: Date / / Account out: Date <br />COMMENTS: <br />\\phs-ehsgl-nt\apps\envisions\reports\5021. rpt <br />