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Date run 3/31/2006 4:41:06PK SAN JOP^UIN COUNTY ENVIRONMENTAL HEAL79 DEPARTMENT Report#5021 <br /> Run by - Pagel <br /> '�✓ Facility Information as of 3/31/2041 <br /> Record Selection Criteria: Facility ID FA0010824 <br /> Make changes/corrections in RED ink'orpencll. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0008822 Case Number: H08817 New Owner ID <br /> Owner Name VINTAGE PETROLEUM LLC <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 916-661-3966 <br /> Mailing Address PO BOX 459 <br /> WOODLAND, CA 95776 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0010824 <br /> Facility Name VINTAGE PETROLEUM LLC <br /> Location 12350 S CROCKER RD <br /> STOCKTON, CA 95206 <br /> Phone 707-374-6428 <br /> Mailing Address PO BOX 609 P. <br /> RIO VISTA, CA 945711230 Ria:c'o ."Cx 'IS o o \ _ '1 5 to S <br /> Care of VINTAGE PETROLEUM LLC <br /> Location Code 99- UNINCORPORATED AREA APN 191-040-02 <br /> BOS District 003 - MOW, VICTOR SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017824 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name VINTAGE PETROLEUM LLC (Circle One) <br /> Account Balance as of 3/31/2006: $0.00 <br /> (Circle One) <br /> Transferto Active/Inadve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owr.O Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0517954 EE0000753-WILLIE NG Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO513112 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR,PR0510824 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourty 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 /> Slate andlor Federal Laws. <br /> APPLICANTS SIGNATURE: Date ! _/ 6(� <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 Received by <br /> REHS: Date Account out: Date <br /> COMMENTS: <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />