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Date run 9/12/2005 3:44:05PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Pagel <br /> Run by lagorio Facility Information as of 9/12/2005 <br /> Record Selection Criteria: Facility ID FA0007880 <br /> Make changesicorrections in RED Ink or pencil. <br /> INFORMATION CHANGE(date) <br /> fling OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0005690 New Owner ID : <br /> Owner Name ARCO <br /> Owner DBA ARCO#760 <br /> Owner Address 4 CENTERPOINTE DR 300 <br /> LA PALMA, CA 90623 <br /> Home Phone 408-2594613 <br /> Work/Business Phone 408-378-8696 <br /> Mailing Address PO BOX 5079 <br /> BUENA PARK, CA 906225077 <br /> Care of PERMITS-LICENSING <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0007880 ---yj' <br /> Facility Name ARCO FACILITY#434 - <br /> Location 501 W KETTLEMAN LN <br /> LODI, CA 95240 <br /> Phone 209-333-0141 <br /> Mailing Address PO BOX 6549 <br /> MORAGA, CA 94570 <br /> Care of PAUL SUPPLE <br /> Location Code 02 - LODI APN: <br /> BOS District 004 -SEIGLOCK, JACK SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0014493 New Account ID: <br /> Mail invoices to Facility Mail Invoices to: Owner I Facility / Account <br /> Account Name ARCO FACILITY#434 (Circle One) <br /> Account Balance as of 911212005: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0508007 EE0000942-MARGARET LAGORIO e Y N A .� " D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlof project specific,PHSlEHD hourly charges associated with this <br /> facility or activitywill 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 Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Date ! 1 <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date 1 / <br /> Water System to be TRANSFERED: *$558.00= Amount Paid Date ! 1 <br /> PaymentCheck Number Received by <br /> pe r~ <br /> REHS: Date ! Account out: Date 1 <br /> COMMENTS: <br /> 11phs-ehsq I-ntlappslenvisio nslreports15021.rpt <br />