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Date run 10/11/2006 4:46:06F SAN JOA'IUIN COUNT`'RNVIRONMENTAL HEAT —M DEPARTMENT Report#5021 <br /> Run by 4006 Paget <br /> Facility Information as of 10/11/2uuo <br /> Record Selection Criteria: Facility ID FA0015020 <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 FA0015020 <br /> Facility Name USA GASOLINE#3513 <br /> Location 401 W KETTLEMAN LN <br /> LODI, CA 95240 <br /> Phone 209-368-8787 <br /> Mailing Address 401 W KETTLEMAN LN <br /> LODI, CA 95240 <br /> Care of <br /> Location Code 02 - LODI APN:04513019 <br /> BOS District 004-SEIGLOCK, JACK v'� SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION f, <br /> Account ID AR0025666 ,, 1 New Account ID: <br /> Mail Invoices to U w Mail Invoices to: Owner / Facility / Account <br /> Account Name D IV (Circle One) <br /> Account Balance as of 10/11/2006: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactva <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR000134 EE0000997-HARLIN KNOLL Active 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 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. n <br /> APPLICANT'S SIGNATURE: Ct�7f�� Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date 10/ l(_/_p_6 <br /> Payment Type Check Number 0 Received by pC <br /> REHS: Date / / Account out: Date /3/ :� <br /> COMMENTS: <br /> 0 P E�V ED <br /> R 11 2066 <br /> �Y SAN JOAaU1NEN ASTM <br /> ENVIRONM <br /> H wtA DEPPARTPAL <br /> \\phs-ehsq I-nt\apps\envisions\reports\5021.rpt <br />