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Date run 10/24/2b03 10:38:38/ SAN JOAN Q COUNTY ENVIRONMENTAL HEALT PARTMENT Report tt5021 <br /> Run by <br /> Facility Information as of 10/24/2003 Pagel <br /> Record Selection Criteria: Facility ID FA0009886 <br /> Make changes/corrections in RED ink or pencil. <br /> FI L E INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0007886 Case Number: H05728 New owner ID <br /> Owner Name JOHN CROOKS <br /> Owner DBA ACE OIL CO <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 209-333-0030 <br /> Mailing Address 20 S CLUFF AVE <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009886 <br /> Facility Name ACE OIL CO <br /> Location 20 S CLUFF AVE <br /> LODI, CA 95240 <br /> Phone 209-333-0030 <br /> Mailing Address zg�-DAVE Z(UZU l t y WA4 ESTE — 6it. <br /> LODI, GA 24e S!k C);/N W G.N To CW Cl 5 X Z-5 —3 ZZ40 <br /> Care of <br /> Location Code 02- LODI APN:049-090-32 <br /> BOS District 004 -SEIGLOCK, JACK SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016886 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name JOHN CROOKS (Circle One) <br /> Account Balance as of 10/24/2003: $0.00 <br /> (Circle One) <br /> Transferto Active/Inachve <br /> ProgremlElemem and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONSNR PR0514082 EE0008389-DENNIS CATANYAG Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0512174 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PR0519938 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0509886 EED000000-HAZ MAT SJC DES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknu Medge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will 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 Ordinace 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: •$155.00= Amount Paid Date <br /> Payment Type Check Number Ived by <br /> REHS: RJk- Date-------------[D / / 0.'3 Account out: _ Date <br /> COMMENTS <br /> .-K y JL"-f�A til L�tit 11 iG�L{ <br /> \\Phs-ehsgl-nt\apps\Envisions\Reports\5021.rpt <br />