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Date run 5/26/2006 1:58:03PA SAN JOAN COUNTY ENVIRONMENTAL HEALT&EPARTMENT Report #5021 <br />Paget <br />Run by <br />Facility Information as of 5/26/2006 <br />Record Selection Criteria: Fact ity ID FA0006943 <br />OWNER FILE INFORMATION <br />Owner ID <br />OW0005703 UU�I� <br />M <br />s �� s <br />Owner Name <br />42ART +bkN-ff4G <br />Owner DBA <br />LATHROP CHEVRON (`PA 1S <br />Owner Address <br />140 LATHROP RD <br />EE0007289 - ALISON YOUNGBLOOD Inactive <br />LATHROP, CA 95330 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />p 7 7 p <br />ga5-478-$^&%„9_0 -'\9,��S <br />Mailing Address 140E LATHROP RD <br />LATHROP, CA 95330 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID FA0006943 <br />Facility Name LATHROP CHEVRON <br />Location 140 E LATHROP RD <br />LATHROP, CA 95330 <br />Phone 209-982-5779 <br />Mailing Address 140 E LATHROP RD <br />LATHROP, CA 95330 <br />Care of <br />Location Code 07 - LATHROP <br />BOS District 003 - MOW, VICTOR <br />4CCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0009855 <br />Mail Invoices to Facility <br />Account Name LATHROP CHEVRON <br />%ccount Balance as of 5/26/2006: $170.00 <br />'roaram/Element and Description <br />Make changes/corrections in RED Ink or pencil. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (dale) <br />New Owner 10 : <br />FARU 19,214 <br />521, i 0 -M <br />Vari$� <br />1151 <br />1^e,}-5qz-q13�? <br />Record ID Employee ID and Name <br />615 - RETAIL MKT 42000 SO FT (PREPKGD / LTCPRO506097 <br />220 - SM HW GEN 45 TONS/YR PRO518581 <br />!224 - HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512906 <br />!244 -PACT TRANSFER RECORD -OES PR0520435 <br />:301 - UST STATE SURCHARGE FEE PRO515563 <br />!361 - UST FACILITY PR0505687 <br />:399 - UNIFIED PROGRAM FAC STATE SURCHARPR0507640 <br />'.399 - UNIFIED PROGRAM FAC STATE SURCHARIPRO518583 <br />APN:19611007 <br />SIC Code:9900 <br />New Account to, <br />Mail Invoices to: Owner / Facility i Account <br />(Ci a ne) <br />Status <br />EE0001699 - JOHNNY YOAKUM <br />Active <br />EE0000753 - WILLIE NG <br />Active <br />EE0000000 - HAZ MAT SJC DES <br />Inactive <br />EE0000000 - HAZ MAT SJC OES <br />Active <br />EE0007289 - ALISON YOUNGBLOOD Inactive <br />EE0000753-WILLIE NG <br />Active <br />EE0007289 - ALISON YOUNGBLOODlnactive <br />EE0008493 - LORI LUCES <br />Inactive <br />ILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHSIEHD <br />tdlity 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 Ordr, <br />tate andlor Federal Laws. A4 <br />,PPLICANTS <br />'rogram Records to be TRANSFERED: ' $20.00 = <br />Vater System to be TfRA ERED: ` $372.00 = <br />ayment Type Check Number ---l-+- / <br />:EHS: Date <br />OMMENTS:T,Cji� yvL i T- Z, <br />Amount Paid <br />Amount Paid <br />Account out: <br />3hs-ehsgl-nt\apps\envisions\reports\5021. rpt <br />(circle One) <br />'to Activelinactve <br />ter? Delete <br />N A I D <br />N A I D <br />N A I D <br />N A 1 D <br />N A I D <br />N A I D <br />N A I D <br />N A I D <br />rges associated with this <br />I andlor Standards and <br />