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n 9/18/2008 2:48:4OPk SAN JOIN COUNTY ENVIRONMENTAL HEADEPARTMENT Report#5021 <br /> un by Pagel <br /> Facility Information as of 9/18/20 <br /> Record Selection Criteria: Facility ID FA0017827 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0014638 New Owner ID <br /> Owner Name MOORE, JAMES G <br /> Owner DBA NEW WEST STATIONS INC <br /> Owner Address 1831 16TH ST <br /> SACRAMENTO, CA 95814 <br /> Home Phone 916443-0890 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1831 16TH ST <br /> SACRAMENTO, CA 95814 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0017827 <br /> Facility Name FLAG CITY SHELL#1003 <br /> Location 6437 W BANNER ST <br /> LODI, CA 95242 <br /> Phone 209-333-1330 <br /> Mailing Address 1831 16TH ST <br /> SACRAMENTO, CA 95242 <br /> Care of NEW WEST STATIONS INC <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 05532019 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name JAMES G MOORE <br /> Title PRESIDENT <br /> Day Phone 209-333-1330 <br /> Night Phone 916443-0890 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0031165 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CLOSURE SOLUTIONS INC (Circle One) <br /> Account Balance as of 9/18/2008: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inacwe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2957-UST FILE-RWOCB PR0526345 EE0000684-MICHAEL INFURNA Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project speck,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 /> Stale and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid 0116. l0 Date / / <br /> Water System to be TRANSF�RED: -*$372.00= Amount Paid Date <br /> Payment Type ✓ Check Number gk Received by 1nZ• <br /> REHS: Date / / Account out: Date <br /> COMMENTS: V u <br /> l So X08' <br /> \\phs-ehsql-nt\a pps\envisions\reports\5021.rpt <br />