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bate run 3/10/2008 4:59:23M SAN JOA11UIN COUNTY ENVIRONMENTAL HEAL"'9 DEPARTMENT Report#6021 <br /> Run by 4006 Pagel <br /> • � Facility Information as of 3/10/20Am <br /> Record Selection Critena: Facility ID FA0012373 <br /> Make changes/corrections in RED Ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW 0009600 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 <br /> Work/Business Phone 209-333-1271 <br /> Mailing Address —7 L) O r.4('f'0 IC �• <br /> LODI, CA 9524•r <br /> Care of <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_PAQ_ @ SJ <br /> LODI, CA 95241 <br /> Care of <br /> Location Code 02- LODI APN 04918019 <br /> BOS 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 / Facility / Account <br /> Account Name MOBIL OIL'N LUBE (Circle One) <br /> Account Balance as of 3/10/2008: $78.00 <br /> (Circle One) <br /> Transfer to Active/maclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2221 -USED OIL ONLY-<5 TONSNR PRO522356 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO515905 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PRO520929 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARIPR0515906 EE0009999-SITE UNASSIGNED Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned comer,operator or agent m same,acknowledge that all site,and/or project specific.PMS/EHD hourly charges associated with this <br /> facility or activity will be billed to the parry 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 aMnor Federal Laws. (� 7 <br /> APPLICANTS SIGNATURE: Ik A t 1. 4_t�LW- \ Date 3 /_ / Dl Q <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 3 / it / () K <br /> COMMENTS: <br /> kVhs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />