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[Recond <br /> te m;Sel..on <br /> /21/2017 8:52.23AA SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> n by Report f/5021 <br /> Facility Information as of 4/21/2017 Pagel <br /> unions: Facility ID FA0019193 <br /> Make changes/corrections in RED ink <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 <br /> SSN/Fed Tax ID <br /> Owner ID OW0004451 New Owner ID <br /> Owner Name Richard E. Sanborn <br /> Owner DBA SANBORN CHEVROLET INC <br /> OwnerAddress 1210 S CHEROKEE LN <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-334-5000 <br /> Mailing Address P.O. BOX 1057 <br /> Lodi, CA 95241-1057 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0019193 10187089 <br /> Facility Name SANBORN CHEVROLET PROLUBE SHOP <br /> Location 1190 S CHEROKEE LN <br /> LODI, CA 95240 <br /> Phone 209-334-5000 x <br /> Mailing Address PO BOX 1057 <br /> LODI, CA 95241 <br /> Care of SANBORN CHEVROLET <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN 04728012 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0034158 New Account ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name SANBORN CHEVROLET PROLUBE SHOP (Circe One) <br /> Account Balance as of 4/21/2017: $0.00 <br /> (Cirde One) <br /> Transfer to Acti nnacwe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0539240 EE0008709-JAMIE LIMA Active Y N A 1 D <br /> 2228-GEN 25<50 TONS PERMIT PRO528517 EE9999998-ONE VACANTI Active Y N A ® D <br /> 2332-EXEMPT TANK FACILITY PRO528518 EE0000030-AARON HANG Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PR0537852 EE9999998-ONE VACANTI Active Y N A ) D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO532142 Inactive Y N A I D <br /> BILLING and COMPLMCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSrl hourty charges associated with this facility <br /> or activity will be billetl to the party identitied as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and State and'a <br /> Federal Laws <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Rece vjg by -7 <br /> EHD Staff: 7 <br /> Date I / Account out: Date,,/ / <br /> lnvoi <br /> COMMENTS: <br /> �5 �#: <br /> �11UfA� +�A V�`�JE7-ZG <br />