Laserfiche WebLink
Date run 10/11/2006 4:26:23F SAN JOA IN COUNTY ENVIRONMENTAL HEAIO DEPARTMENT <br /> Report#5021 <br /> Pagel <br /> Run by 4006 FacNi'v iraormation as of 10/11/2006 <br /> Record Selection Criteria: Facility ID FA0015023 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0011025 New Owner ID <br /> Owner Name USA PETROLEUM CO <br /> Owner DBA USA PETROLEUM CO <br /> Owner Address 905 RANCHO CONEJO BLVD <br /> NEWBURY PARK, CA 913201716 <br /> Home Phone 805-214-9200 <br /> Work/Business Phone 805-214-0925 <br /> Mailing Address 905 RANCHO CONEJO BLVD <br /> NEWBURY PARK, CA 913201716 <br /> Care of ALONSO, OLIVIA <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015023 <br /> Facility Name USA GASOLINE#3502 <br /> Location 35 N CHEROKEE LN <br /> LODI, CA 95240 <br /> Phone 209-369-1525 <br /> Mailing Address 35 N CHEROKEE LN <br /> LODI, CA 95240 <br /> Care of <br /> Location Code 02 - LODI <br /> APN:04318003 <br /> BOS District 004 - SEIGLOCK, JACK SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0025669 �� New Account ID: <br /> Mail Invoices to AQgEn'ft- v W r212 Mail Invoices to: Owner / Facility / Account <br /> (Circle One) <br /> Account Name <br /> Account Balance as of 10/11/2006: $0.00 (Circle One) <br /> Transfer to Active/Inactve <br /> New Owners Delete <br /> Program/Element and Description Record ID Employee ID and Name Status <br /> 2950-ENVIRON ASSESS PR0522056 EE0000997-HARLIN KNOLL Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the un er,operator or agent of same,acknowledge that all site,and/or project specific,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 /> State and/or Federal Laws. <br /> Date <br /> APPLICANT'S SIGNATURE: / / <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Datey / /O� <br /> Water System to be TRA FERED: *$372.00= Amount Paid b��S 'Date / 1O / <br /> Payment Type Check Number 1-1,003 Received by 'l e - <br /> REHS: Date / / Account out: Date d <br /> COMMENTS: <br /> PAYMENT <br /> RECEIVED <br /> OCT 11 Zk <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL <br /> HEALTH DEPARTMENT <br /> \\phs=ehsgl-nt\apps\envisions\reports\5021:rpt <br />