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Date run 7/23/2007 12:32:57PI SAN JO ,UIN COUNTY ENVIRONMENTAL HEAL—'I DEPARTMENT Report#5021 <br /> Run by 1273 Pagel <br /> _ Facility Information as of 7/23/20070" <br /> Record Selection Criteria: Facility ID FA0010042 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0011689 New Owner ID <br /> Owner Name MONTGOMERY, MARIA LUISA <br /> Owner DBA ALL TUNE AND LUBE <br /> Owner Address 3709 BLACKEAGLE DR <br /> ANTELOPE, CA 958435501 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-333-6234 <br /> Mailing Address 3709 BLACKEAGLE DR <br /> ANTELOPE, CA 958435501 <br /> Care of MONTGOMERY, MARIA LUISA <br /> FACILITY FILE INFORMATION <br /> Facility 1D FA0010042 <br /> Facility Name ALL TUNE AND LUBE .c <br /> Location 923 S CHEROKEE LN l <br /> LODI, CA 95240 ( �Z <br /> Phone 209-333-6234 <br /> Mailing Address 3709 BLACKEAGLE DR <br /> ANTELOPE, CA 958435501 <br /> Care of MONTGOMERY, MARIA LUISA <br /> Location Code 02-LODI APN:04739006 <br /> BOS District 004-VOGEL, KEN SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017042 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name ALL TUNE AND LUBE �� (Circle One) <br /> Account Balance as of 7/23/2007: $436:68-1W�wu <br /> (Grief One) <br /> VVTransfer to Active/Inactve <br /> PrograMElement and Description Record ID Employee ID antl Name Status New Owner? Delete <br /> 2220-SM HW GEN c5 TONS/YR PRO514141 EE0009155-TOUA YANG Active Y N A 0 D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0512330 EEOOOOOOO-HAZ MAT SJC DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PRO522273 Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARFIR0510042 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO524081 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and1w pmject spec,PHS/EHD hourly charges associated with this <br /> facility or activity volt be billed to the party identified as the OWNER on this form. I also certify that all operations will be Performed in accordance with all applicable Ordlnace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: 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 Recei�ve vJ�y <br /> RENS: Date / / Account out: 1'-� Date <br /> COMMENTS: <br /> \\phschsgl-nt\apps\envisions\reports\5021.rpt <br />