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FDWemn2/27/2015 8:51:39AA SAN JO�JIN COUNTY ENVIRONMENTAL HEAD DEPARTMENT Report 15021 <br /> Facility Information as of 2/27/2015 Pagel <br /> ction unions, Facility ID FA0019193 <br /> Make changesicorrections in RED ink. n <br /> INFORMATION CHANGE(date) _ L 2,- <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 SANBORN CHEVROLET INC <br /> Owner DBA SANBORN CHEVROLET INC <br /> Owner Address 1210 S CHEROKEE LN <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-334-5000 <br /> Mailing Address PO BOX 1057 <br /> LODI, CA 95241-1057 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/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 /> BOIS 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 . I�/Ir/,� (� <br /> Account ID AR0034158 U" New Account ID: <br /> Mail Invoices to Facility J Mail Invoices to: Owner / Facility / Account <br /> Account Name SANBORN CH E LET PROLUBE SHOP (Circle One) <br /> Account Balance as of 2/27/2015: $2,2 .00 <br /> (Circle One) <br /> PrograMElement and Description RecordID Employee ID and NaTransfer to Activellnadve <br /> Nae Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO539240 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2228-GEN 25<50 TONS PERMIT PRO528517 EE0001422-ARIS VELOSO Active Y N A CD D <br /> 2332-EXEMPT TANK FACILITY PRO528518 EE0001422-ARIS VELOSO Inactive Y N A I D <br /> 2831 -AST FAC >/=1,320-<10 K GAL CUMULATIVE PRO537852 EE0001422-ARIS VELOSO Active Y N A ® D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532142 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSEHD hourly charges associated with Mis facility or: <br /> be billed to Me party identified!as Me OWNER on Mis form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes arol Standards and State andor Federal Laws. <br /> APPLICANT'S 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 Received y <br /> REHS: _ K3 1'ht, Date _ Account out: Date_/ / <br /> COMMENTS: <br />