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Date run 6/5/2006 2:36:22PM SAN JOAOUIN COUNTY ENVIRONMENTAL HEALT14 DEPARTMENT Report #5021 <br />Run by 1273 <br />Facility Information as of 6/5/200,. Pagel <br />Record Selection Criteria: Facility'ID FA0013644 <br />Make changes/corrections in RED ink or pencil. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION <br />Owner ID OW0010757 NPW Owner ID <br />Owner Name HOLSWORTH, DON <br />Owner DBA OUT WEST AUTO <br />Owner Address 5403 PETTINGER RD <br />VALLEY SPRINGS, CA 95252 �9�f ►V' <br />Home Phone 209-772-1931 <br />Work/Business Phone Not Specified <br />Mailing Address 5403 PETTINGER RD f ` <br />VALLEY SPRINGS, CA 95252 <br />Care of DON HOLSWORTH <br />FACILITY FILE INFORMATION <br />Facility ID FA0013644 �y <br />Facility Name OUT WEST AUTO�}T <br />� ar <br />Location 720 E LODI AVE <br />LODI, CA 95240 <br />Phone 209-367-9870 <br />Mailing Address 720 E LODI AVE <br />LODI, CA 95240 <br />Care of DON HOLSWORTH <br />Location Code APN:04745013 <br />BOS District 004 - SEIGLOCK, JACK SIC Code:9900 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0022800 New Account ID: <br />Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br />Account Name OUT WEST AUTO (Circle One) <br />Account Balance as of 6/5/2006: $424.00 <br />(Circle One) <br />Transfer to Active/Inaclve <br />Program/Element and Description Record ID Employee ID and Name Status <br />New Owner? Delete <br />2220 - SM HW GEN <5 TONS/YR PRO517990 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 IDES Inactive Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHAR(PR0517992 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 />State and/or Federal Laws. <br />APPLICANT'S SIGNATURE: �— Date Y.`/ / <br />Program Records to be TRANSFERED: * $20.00 = Amount Paid <br />Water System to be TRANSFERED: * $372.00 = Amount Paid <br />Payment Type Check Number <br />REHS: Date <br />COMMENTS: <br />\\phs-ehsq I-nt\apps\envisions\reports\5021. rpt <br />Date <br />Date <br />Received by <br />Account out: Date <br />