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Date con 4/24/2006 10:59:51AI SAN JOA'1UIN COUNTY ENVIRONMENTAL HEAL'11 DEPARTMENT Report#5021 <br /> Run by Pagei <br /> Facility Information as of 4/24/20bd <br /> Record Selection Criteria. Facility ID FA0010824 <br /> Make changes/correctionsINFORMATIC in RED ink or pt3 . <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 LtC ✓ �� �" <br /> Location 12350 S CROCKER RD <br /> STOCKTON, CA 95206 <br /> Phone 707-374-6428 <br /> Mailing Address PO BOX 2565 <br /> ADDISON, TX 750012565 <br /> Care of VINTAGE PETROLEUM LLC <br /> Location Code 99- UNINCORPORATED AREA APN 191-040-02 <br /> BOIS 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 4/24/2006: $0.00 <br /> (Circle One) <br /> Transferto Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? 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 AUTHORIZATIOIPR0513112 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 specRic,PHS/EHD houry 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 andlor Standards and <br /> Stale andfor Federal Laws. <br /> APPLICANTS SIGNATURE: P G.C�4ca,.o.1� Date 1/�J Ota <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: Cr— Datel_- <br /> COMMENTS' <br /> \\phs-e hsgl-nt\apps\e nvisions\reports\5021.rpt <br />