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Report#5021 <br /> 3:23F SAN JOAN COUNTY ENVIRONMENTAL HEAL <br /> EPARTMENT Pagel <br /> Fa,f ity Inf-irmation as of 10/111200 <br /> Facility ID FA0015023encil. <br /> Make changeslcorrections in RED ink or p <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> ,41FORMATION New Owner ID <br /> Owner ID OW0011025 <br /> Owner Name USA PETROLEUM CO <br /> Owner DBA USA PETROLEUM CO LVD <br /> owner Address NEWBURY HO ARK, CA 913201716 <br /> Home Phone 805-214-9200 <br /> Work/Business Phone 805-214-0925 <br /> LVD <br /> Mailing Address 905 RANCHO <br /> PAROK, CA 913201716 <br /> Care of ALONSO, OLIVIA <br /> ACILITY 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 /> �-APN:04318003 <br /> Care of <br /> Location Code 02-LODI SIC Code:9900 <br /> BOS District 004-SEIGLOCK, JACK <br /> ACCOUNTS RECEIVABLE FILE INFORMATION New Account ID: <br /> Account ID AR0025669Mail invoices to. Owner 1 Facility / Account <br /> W tj (Circle One) <br /> Mail Invoices to A <br /> Account Name (Circle One) <br /> Transfer to Active/Inactve <br /> Account Balance as of 1011112006: $0.00 New Owner? Delete <br /> Status <br /> Record ID Employee ID and Name Y N A I D <br /> Program/Element and Description PRO522056 EE0000997-HARLIN KNOLL <br /> Active <br /> pro <br /> p livable Ordinate <br /> BILLING and COMPLIANCE ACCodes and/or Standards and <br /> NOWLE <br /> I also certify that <br /> facility or activity will be billed to the party identified erations will be performed in accordance with all applicable <br /> DGEMENT: I,the undersigned owner,operator or agent ail o of same,acknowledge that all site,and/or ject specific,PHS/EHD hourly charges associated with this <br /> 2950-ENVIRON ASSESS tified as the OWNER on this form. <br /> State and/or Federal Laws. <br /> Date I 1 <br /> APPLICANT'S SIGNATURE: Date <br /> $20.00= Amount Paid O <br /> Amount Paid b- Date /0 <br /> 7- <br /> 37200 / <br /> Program Records to be TRANSFERED: = y 3 <br /> Water System to be T �I6FERED: Received by <br /> RAf / ( / <br /> Check Number _ Date <br /> Payment Type Date I / Account out: <br /> REHS: ��/� Yti�IEN <br /> COMMENTS: n ` PJ 1ivE <br /> IP L <br /> SAN JOAQUIN COUNTY <br /> TMTH0EPAOW <br /> NAL f- <br /> \\phs-ehsgl-nt\apps\envision s\reports\5021.rpt <br />