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Date run 6/5/2006 2:36:22PM SAN JOA "'JIN COUNTY ENVIRONMENTAL HEAL ` DEPARTMENT Report#5021 <br />Run by 1273 Pagel <br />FiDcility Information as of 6/5/200 <br />Record Selection Criteria: Facility ID FA0013644 _ r'- n <br />OWNER FILE INFORMATION <br />SUN 21 2006 <br />arvM � ��c L1H <br />Owner ID OW0010757 PER,W I i sEN Owner ID . <br />Owner Name HOLSWORTH, DON Zi41Z<F� i�-1 <br />Owner DBA OUT WEST AUTO,�7-�,� g e5r �► >~+� <br />Owner Address 5403 PETTINGER RD <br />VALLEY SPRINGS, CA 95252 \'OM1q705 <br />Home Phone 209-772-1931 1� <br />Work/Business Phone Not Specified ��� <br />Make changes/corrections in RED ink or pencil. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />Mailing Address 5403 PETTINGER RD <br />VALLEY SPRINGS, CA 95252 <br />Care of 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 />��. <br />d� : • A • <br />7 -LO t%_ 1 00 f <br />Lyn4 "152g0 <br />APN:04745013 <br />SIC Code:9900 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0022800 <br />New Account ID: <br />Mail Invoices to Facility <br />Mail Invoices to: Owner / <br />Facility / <br />Account <br />Account Name OUT WEST AUTO <br />(Circle One) <br />Account Balance as of 6/5/2006: $424.00 <br />(Circle One) <br />Transfer to <br />Active/Inactve <br />Program/Element and Description Record ID <br />Employee ID and Name Status <br />New Owner? <br />Delete <br />2220 - SM HW GEN <5 TONS/YR PRO517990 <br />EE0008493 - LORI LUCES Active <br />Y N <br />A I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHOR IZATIOIPR0517991 <br />EE0000000 - HAZ MAT SJC OES Inactive <br />Y N <br />A I D <br />2244 - PACT TRANSFER RECORD - OES PR0521048 <br />EE0000000 - HAZ MAT SJC OES Inactive <br />Y N <br />A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHAR1PR0517992 <br />EE0000000 - HAZ MAT SJC OES Inactive <br />Y N <br />A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, 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 al7ertify <br />that all operations will be performed in accordance with all applicable Ordinace <br />Codes and/or Standards and <br />State and/or Federal Laws. A �� <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRA SFERED: <br />Payment Type Check Number <br />REHS: <br />COMMENTS: <br />P, <br />"� <br />\\phs-ehsql-nt\apps\envisions\reports\5021. rpt <br />Date <br />Amount Paid <br />Amount Paid <br />Account out: <br />Date Z/// IQ� <br />1 �• vDat I (� <br />Date/ <br />Received by <br />Date <br />4�1 /,�7 & —)-0/ P—/J/ /947 <br />