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Date ran 2/27/2015 8:52:19AN SAN JI..,,yJIN COUNTY ENVIRONMENTAL HEA,,,.4 DEPARTMENT Relwrt#5021 <br /> Run by <br /> Facility Information as of 2/27/2015 Pagel <br /> Record Selection Criteria: Facility ID FA0005626 <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 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 FA0005626 10181899 <br /> Facility Name SANBORN CHEVROLET INC <br /> Location 1210 S CHEROKEE LN <br /> LODI. CA 95241 <br /> Phone 209-334-5000 x <br /> Mailing Address PO BOX 1057 <br /> LODI, CA 95241-1057 <br /> Care of richard Sanborn <br /> Location Code 02 - LODI Alt Phone <br /> SOS District 004 -WINN. CHARLES Fax <br /> APN 04728013 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 AR0006259 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name SANBORN C ROLET INC (Circle One) <br /> Account Balance as of 2/27/2015: $2, 7.00 <br /> (Circle One) <br /> Transfer to Active/Inadve <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0519414 EE0008709-JAMIE DE LA ROSA Active Y N A 1 D <br /> -HAZ MAT BUSINESS PLAN AUTHORIZATION PRO511429 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2227 GEN 5<25 TONS PERMIT PR0505935 EE0001422-ARTS VELOSO Active Y N A I D <br /> 1 -UST FACILITY(BEFORE 1/84)-obsolete PRO502946 EE0000005-FATINAH ZAREEF Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0507602 EE0000005-FATINAH ZAREEF Inactive Y N I D <br /> AST EXEMPT FAC <1,320 GAL PR0528318 EE0001422-ARIS VELOSO Inactive Y N I D <br /> 474 -WASTE TIRE SITE-EXEMPT PR0522805 EE0002622-BENJAMIN ESCOTTO Active Y N I D <br /> ERSC-ELECTRONIC REPORTIEG STATE SURC 0532289 Inactive Y N A I D <br /> BILLING an M IA�NC�A KN WW1LEEDG NT, fro ntleri edowner,opera rotagent of.ame,acknowledge that all site,andlor project specific,PH&EHD hourly charges associated with misfacilay or <br /> bi the ah,,, as the OWNER this for I also certify that all operati he will be performed in accordance with all applicable Ordinance Codes anotor Standards and State shoot Federal Lam <br /> C cey <br /> APPL ANT'S SIGNATUR 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 b <br /> REHS: Date_`/�/� Account out: _ Date 77 /�1i� <br /> COMMENTS: <br />