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Date run' 8/11/2009 8:19:39AN SAN JOIN COUNTY ENVIRONMENTAL HEA: DEPARTMENT Report#5021 <br /> .Run-by Pagel <br /> Facility Information as of 8/11/2009 <br /> Record Selection Criteria: Facility ID FA0019174 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0011397 New Owner ID <br /> Owner Name LINCOLN PROPERTIES LTD <br /> Owner DBA LINCOLN PROPERTIES LTD <br /> Owner Address 374 LINCOLN CENTER <br /> STOCKTON, CA 95207 <br /> Home Phone 209-478-9200 <br /> Work/Business Phone Not Specified <br /> Mailing Address 374 LINCOLN CENTER <br /> STOCKTON, CA 95207 <br /> Care of BILL JOHNSON <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0019174 <br /> Facility Name CHEVRON SERVICE STATION 9-6171 <br /> Location 6633 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Phone <br /> Mailing Address PO BOX 7611 <br /> SAN FRANCISCO, CA 94120 <br /> Care of LINCOLN PROPERTIES LTD <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 09741048 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION > <br /> Contact Name JOHNSON, PHIL f .G-f-Ulf %t�! ��'°'rr- �• . <br /> Title <br /> Day Phone 209-478-9200 <br /> Night Phone cs2 ��'i•=";.D. <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0034126 `/ New Account ID: <br /> / a,+� '� <br /> Mail Invoices to Account [�J� G Mail Invoices to: Owner / Facility / Account <br /> Account Name ARCADIS•US"INC ✓��� (Circle One <br /> Account Balance as of 8/14/2009: $105.00 ; fJ,� �_..,, , t/r;1. � !r0 <br /> ry ,l 1 (Circle One) <br /> (, \ Ari�i !/�� Transfer to Active/Inactve <br /> Program/Element and Description C `1 Record ID Employee ID and Name Status New Owner? Delete <br /> 2957-UST FILE-RWQCB PR0528433 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,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 Ordinate Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be�TRANSFERED: *$372.00= Amount Paid Date <br /> Payment Type 1 * Check Number Received by <br /> REHS: Date a� / j ( /X 1 Account out: Date <br /> COMMENTS: (' <br /> \\eh-env\envision\reports\5021.rpt <br />