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Date run 6/5/2006 2:32:15PM SAN JOi' —'JIN COUNTY ENVIRONMENTAL HEAL —1 DEPARTMENT Report #5021 <br />Run by 1273 , I Pagel <br />Facility Information as of 6/5/200u <br />Record Selection Criteria: Facility ID FA0013644 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0010757 <br />Owner Name <br />HOLSWORTH, DON <br />Owner DBA <br />OUT WEST AUTO <br />Owner Address <br />5403 PETTINGER RD <br />Phone <br />VALLEY SPRINGS, CA 95252 <br />Home Phone <br />209-772-1931 <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />5403 PETTINGER RD <br />VALLEY SPRINGS, CA 95252 <br />Care of <br />DON HOLSWORTH <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0013644 <br />Facility Name <br />OUT WEST AUTO <br />Location <br />720 E LODI AVE <br />LODI, CA 95240 <br />Phone <br />209-367-9870 <br />Mailing Address 720 E LODI AVE <br />LODI, CA 95240 <br />Care of DON HOLSWORTH <br />Location Code <br />BOS District 004 - SEIGLOCK, JACK <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0022800 <br />Mail Invoices to Facility <br />Account Name OUT WEST AUTO <br />Account Balance as of 6/5/2006: $424.00 <br />Program/Element and Description <br />Make changes/corrections in RED ink or pencil. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />New Owner ID <br />, <br />D� <br />S� <br />D 19 T '.S I'Alaa2 IR <br />APN:04745013 <br />SIC Code:9900 <br />Record ID Employee ID and Name <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Status New Owner? Delete <br />2220 - SM HW GEN <5 TONS/YR PR0517990 EE0008493 - LORI LUCES Active Y N A I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO517991 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />2244 - PACT TRANSFER RECORD - OES PR0521048 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHAR1PR0517992 EE0000000 - HAZ MAT SJC OES 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 <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: 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-ehsq I-nt\apps\envisions\reports\5021. rpt <br />