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Date run 11/13/2002 10:02:12/ SAN JO) IN COUNTY ENVIRONMENTAL HEA] DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 11/13/2002 <br />Record Selection Criteria: Facility ID FA0013644 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0010757 <br />Owner Name <br />PRICE, TOM <br />Owner DBA <br />GASOLINE ALLEY <br />Owner Address <br />Home Phone <br />209-365-6747 <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />720 E LODI AVE <br />LODI, CA 95240 <br />Care of <br />TOM PRICE <br />FACILITY FILE INFORMATION <br />Facility ID <br />FA0013644 <br />Facility Name <br />GASOLINE ALLEY <br />Location <br />720 E LODI AVE <br />LODI, CA 95240 <br />Phone <br />209-365-6747 <br />Mailing Address <br />720 E LODI AVE <br />LODI-CA 95240 <br />Care of <br />TOM PRICE <br />Location Code <br />BOS District <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID <br />AR0022800 <br />Mail Invoices to <br />Facility <br />Account Name <br />GASOLINE ALLEY <br />Account Balance as of 11/13/2002: <br />$0.00 <br />Program/Element and Description <br />Record ID <br />Employee ID and Name <br />Make changes/corrections in RED ink or pencil. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />New Owner ID <br />APN: <br />SIC Code: <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 TONSNR PR0517990 EE0009903 - DOUG WILSON Active Y N A I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0517991 EE0000000 - HAZ MAT SJC OES Active Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SERVICE FPR0517992 EE0000000 - HAZ MAT SJC OES 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 />State and/or Federal Laws. <br />APPLICANT'S SIGNATURE <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />REHS: <br />COMMENTS <br />\\Phs-ehsql-nt\apps\Envisions\Reports\5021. rpt <br />Date <br />$20.00 = Amount Paid Date <br />$155.00 = Amount Paid Date <br />Received <br />by - <br />Date / / Account out: Date <br />