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Date run 11/6/2002 1:33:11K SAN JOA IN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by <br /> w Facility Information as of 11/6/2002 Pagel <br /> Record Selection Cnteria: Facility ID FA0010824 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) --�- <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION r/ <br /> / /j <br /> Owner ID OW0008824 Case Number: H08819 New Owner ID : Y 1142 <br /> Owner Name VINTAGE PETROLEUM INC <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/BusinessPhone 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 INC <br /> Location 12350 S CROCKER RD <br /> STOCKTON, CA 95206 70 <br /> Phone 707-374-6428 <br /> Mailing Address 60 RIVER RD _ <br /> RIO VISTA, CA 95776 <br /> Care of VINTAGE PETROLEUM INC <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 Account Mail Invoices to: Owner / Facility / Account <br /> Account Name VINTAGE PETROLEUM INC (Circle 01 <br /> Account Balance as of 11/6/2002: $0.00 <br /> (Circle One) <br /> Transfer to Actnednactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 2220-SM HW GEN<5 TONSNR PR0517954 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIO PR0513112 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPR0510824 EE0000000-HAZ MAT SJC DES Active 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,PHSIEHD hourly charges associated with this <br /> facility or activity will be billed to the parry identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes andlor Standards and <br /> State and/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: "$155.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> Phs-ehsgl-ntlapps\Envisions\Reports\5021.rpt <br />