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Datevm 4{,2/2008 8:06:52AM SAN JQAOUIN COUNTY ENVIRONMENTAL HEAI TH DEPARTMENT Repon#502f <br /> Run by 4006 Pagel <br /> '—� Facility Information as of 4l2/20be4 <br /> Record Selection Criteria: Facility ID FA0012373 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> FILE <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION. <br /> Owner ID OW0009600 New Owner ID <br /> Owner Name MOBIL OIL'N LUBE <br /> Owner DBA MOBIL OIL'N LUBE <br /> Owner Address 1108 BLACK DIAMOND <br /> LODI, CA 95240 <br /> Home Phone Not Specified 327-37aJ Cc" <br /> Work/Business Phone 209-333-1271 <br /> Mailing Address 700 TAHOE DR <br /> LODI, CA 952422157 <br /> Careof ?-A1fnAs+-Z IAPEZ <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0012373 <br /> Facility Name MOBIL OIL'N LUBE <br /> Location 1108 BLACK DIAMOND WAY#B <br /> LODI, CA 95240 <br /> Phone 209-369-6668 <br /> Mailing Address 700 TAHOE DR <br /> LODI, CA 952422157 <br /> Care of <br /> Location Code 02 - LODI APN 04918019 <br /> BOIS District 004 -VOGEL, KEN SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0020227 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner I Facility I Account <br /> Account Name MOBILIL'N LUBE (Circle One) <br /> Account Balance as of 4/2/2008: Its <br /> (Circe One) <br /> Transfer to Activennadve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner D e <br /> 2221-USED OIL ONLY-<5 TONS/YR PRO522356 EE0001422-ARIS CACAPIT A Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO515905 EEOOOOOOO-HAZ MAT SJC OES Inactive Y N A D <br /> 2244-PACT TRANSFER RECORD-DES PRO520929 EEOOOOOOO-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARFIR0515906 EE0009999-SITE UNASSIGNED 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 projed 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. 1 also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State andlor Federal Laws. <br /> APPLICANTS SIGNATURE: " �"— �7�Tc 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_ 1.2-- <br /> COMMENTS: .Z.-COMMENTS: <br /> �NRtT✓f1-1C 47 1� �v 51 U �� S �d�L /L it tj DA <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />