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Date run 1/23/2006 9:02:0 � Report#5021 <br /> JIN COUNTY ENYHtONMENTAL HEAf <br /> 5AM SAN J � DEPARTMENT Pagel <br /> Run by 5290 <br /> Facility Information as of 1/23/2006Retard Selection Criers: Facility ID FA0010042 <br /> � Make changes/corrections in RED ink or pencil. <br /> '1— NPs 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 923 CHEROKEE LN -70y112 Pd.e./i . <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-333-6234 91& - 338 - 17.3(0 <br /> Mailing Address 923 CHEROKEE LN <br /> LODI, CA 95240 (nnv.� 581f3 - SSD / <br /> Care of MONTGOMERY, MARIA LUISA <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010042 <br /> Facility Name ALL TUNE AND LUBE <br /> Location 923 S CHEROKEE LN <br /> LODI, CA 95240 <br /> Phone 209-333-6234 <br /> Mailing Address 923 S CHEROKEE LN 370 q aa- �- <br /> STOCKTON, CA 95240 LU� , &ft3 - 5Sb I <br /> Care of MONTGOMERY, MARIA LUISA <br /> Location Code 02- LODI APN:047-390-06 <br /> BOS District 004- SEIGLOCK, JACK SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017042 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to. Owner / Facility I Account <br /> Account Name ALL TUNE AND LUBE (Circle One) <br /> Account Balance as of 1/23/2006: $0.00 <br /> (Cirde One) <br /> Transfer to ACivednadve <br /> PrograrnMemad and Description Record ID Employee ID and Name Status New O ery Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO514141 EEODDS493-LORI LUCES Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIONPRO512330 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PRO522273 Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARCPRO510042 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO524081 EE0004636-GARRETT BACKUS Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,me undersigned owner,operator or agent of sane,acknoMedge that dl site,and/or project specific,PHS/EHO hourly changes associated with this <br /> facility or activity will be billed to the party identified as Me OWNER on this form. I also candy met all operations will be performed in accordance with all applicable Ordinate Codes a dlor Standards and <br /> State aid/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date_/ / <br /> Water System to be TRANSFERED: '$372.00= Amount Palo Date <br /> Payment Type Cheek Number Received by <br /> RENS: Date_/ / Account out: .A Date l a'3/ Ory <br /> COMMENTS: <br /> i� <br /> \\phs-ehsgl-nt\apps\envisions\reponsG5021.rpt <br />