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Date run 2/4/2005 8:21:53AM SAN JOAW COUNTY ENVIRONMENTAL HEALEPARTMENT Report 41021 <br /> Run by Pagel <br /> % Facility Information as of 2/4/2005 <br /> Record Selection Criteria: Facility ID FA0003815 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0002829 New Owner ID <br /> Owner Name KRISTMONT WEST, INC <br /> Owner DBA USA GASOLINE CORP <br /> Owner Address 2830 N G ST <br /> SACRAMENTO, CA 93816 <br /> Home Phone Not Specified <br /> Work/Business Phone 818-865-9200 <br /> Mailing Address 30101 AGOURA CT#200N rglfFSDZ(/l� <br /> AGOURA HILLS, CA 91301xl c �Pdrk <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0003815 <br /> Facility Name USA GASOLINE#65 <br /> Location 2500 W LODI AVE <br /> LODI, CA 95240 <br /> Phone 209-333-9834 n/�� <br /> Mailing Address 30101 AGOURA CT#200 qvy _T 1 <br /> AGOURA HILLS, CA 91301 <br /> Care of <br /> Location Code 02-LODI APN: <br /> BOIS District 004-SEIGLOCK, JACK SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003402 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name USAGASOLINE#65 (CirdeOne) <br /> Account Balance as of 2/4/2005: $1,259.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee 10 and Name Status New Omer? Delete <br /> 1615-RETAIL MKT<2000 SO FT (PREPKGD/LTCPR0505107 EE0003361 -MARIBEL FLOHRSCHUYkctive Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PR0516543 EE0008389-DENNIS CATANYAG Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0511902 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0519773 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2301 -UST STATE SURCHARGE PR0508263 EE0003580-MICHELLE LE Inactive Y N A I D <br /> 2361 -NEW MULTI UST FACILITY PR0231366 EE0008389-DENNIS CATANYAG Active Y N A 1 D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPRO506801 EE0003580-MICHELLE LE Inactive Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor 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 andlor Standards and <br /> State andror Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: _*$156.00= Amount Paid Date <br /> Payment Type Check Number Received bty <br /> REHS: Date_/ /_ Account out: <br /> COMMENTS: L <br /> \\phs-ehsq I-nt\apps\envisions\reports\5021.rpt <br />