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Date run 3/2/2010 4:34:43PM SAN JOr `'IN COUNTY ENVIRONMENTAL HEAL'"'DEPARTMENT Report M5021 <br /> Ran by1273 C ' y� Pagel <br /> - <br /> Facility Information as of 3/2/201 <br /> Record Selection Criteria: FarAiry ID FA0009876 <br /> Make changesicorrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) 1 - / - <br /> OWNER <br /> - / -OWNER FILE INFORMATION SSN/Fad Tax ID <br /> Owner ID OW0007876 Case Number: H05707 Ne Owner ID <br /> Owner Name G'S AUTO WORKS INC ` N <br /> Owner DBA g } <br /> Owner Address 324 N CLUFF AVE <br /> LODI, CA 95240 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-333-6250 ;tri <br /> Mailing Address 324 N CLUFF AVE <br /> LODI, CA 95240 <br /> Care o \oha 2u <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009876 <br /> Facility Name T t If SMo4i <br /> Location 324 N CLUFF AVE <br /> LODI, CA 95240 <br /> Phone 209-334-6332 <br /> Mailing Address 324 N CLUFF AVE <br /> LODI, CA 95240 `,�J 1- <br /> Care of D hj,I 'zybt.' Psi.I <br /> Location Code 02- LODI Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 049-080-70 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION L <br /> Contact Name \OhN 2-UIiNM <br /> Title <br /> Day Phone n pza .r __ <br /> Night Phone 1/J - <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0016876 NewAcoount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility I Account <br /> Account Name BLAINE DEJONG'S AUTO WORKS INC (Circle One) <br /> Account Balance as of 3/2/2010: .$4392.00 <br /> 7/5.•-V (kR,(,(J /rn/ I LJL�� (Girds One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Omen Delete <br /> 2220-SM HW GEN<5 TONS/YR PRO514075 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0512164 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PR0519932 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR IR0509876 EED000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PRO534664 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge mat all site,and/or project specific,PHS/EHO dourly charges associated with this <br /> facility or activity M11 be billed to the party identified as the OWNER on this forth. I also certify mat all operations will be performed in accordance with all applicable Ordinace Codes andlor Standards and <br /> State andlor 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 TypevT,Check Number Recei <br /> REHS: Date��J-_/�/ (O Account out: Date / /L <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />