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xun Dy : NURA San Joaquin County PHS/EHD Report #5021. <br /> FACILI' v INFORMATION as of 07/24/or- <br /> __.`�-.----------------------- <br /> Make changes/corrections in RBD pen or pencil: <br /> OWNER FILE INFORMATION INFORMATION CRANG3 (date): <br /> 0WNERSHIP CHANGE (date): <br /> 0WNER ID: 001987 New Owner ID: 00 <br /> Owner Name: CHEVRON USA <br /> Owner DBA: <br /> Owner Address: 2410 CAMINO RAMON <br /> SAN RAMON, CA 94583 <br /> Home Phone: 510-842-9002 <br /> worklBusiness Phone: 209-956-2520 <br /> Mailing Address: PO BOX 5004 <br /> Care of: KATHY NORRIS/PERMIT DESK <br /> SAN RAMON, CA 94583 <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 004067 <br /> Facility Name: CHEVRON SERVICE STA 9-4183 <br /> Location; 236 N HAM LN <br /> LODI 95242 <br /> Phone: 510-682-1582 <br /> Nailing Address: ±0 0 0 , <br /> Care of: AhTON <br /> .S1D) 8 <br /> G - 1 <br /> Location Code: 02 APN: <br /> BOS District: SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0003723 New Account ID: 000 <br /> Mail Invoices tai Facility Nail Invoices to: Owner / Facility / Account <br /> Account Name: CHEVRON SERVICE STA 9--4183 (Circle one) <br /> Account Balance as of 07/24/95 : $0 . 00 (Circle one) <br /> Record UST(s) Transfer to Activate I Inactivate <br /> P/E— Description--- ------ ID --- Em 1 yee Status Linked new owner? ' Delete <br /> �� - I ------------------------------------------ <br /> 2959 ENVIRON ASSESS PRO01333 I=N ACTIVE Y N A I D <br /> --------------------------------------------------------—---------------------- <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PHSIERD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. I also certify that all operations.will be performed in accordance with all applicable SAN JOAQUIN <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / 1 <br /> ------------------------------------------------------------------------------- <br /> PR Records to be TRANSFERED: x $20.00 = Amount Paid Date I I <br /> (dater System to be TRANSFERED: x 5150.00 = Amount Paid Date <br /> Payment Type Check 0 Recvd by <br /> REBS or COUNTER SUPV: Date—/—/ ACCT out: Date 7 / T / S UNIT/Pile: <br />