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Date run 8/25/2003 1:46:26PK SAN Y \UIN COUNTY ENVIRONMENTAL HE. H DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/25/2003 <br /> Record Selection Criteria: Facility ID FA0014276 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0011331 New Owner ID <br /> Owner Name CHEVRON PRODUCTS COMPANY <br /> Owner DBA CHEVRON PRODUCTS COMPANY <br /> Owner Address PO BOX 6004 <br /> SAN RAMON, CA 94583 <br /> Home Phone 925-842-9655 <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 6004 <br /> SAN RAMON, CA 94583 <br /> Care of COCHRAN, BOB <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014276 <br /> Facility Name CHEVRON BULK TERMINAL 100-1621 "UST <br /> Location 22888 S KASSON RD <br /> BANTA, CA 95304 <br /> Phone 209-835-1097 <br /> Mailing Address PO BOX 6004 <br /> SAN RAMON, CA 94583 <br /> Care of <br /> Location Code 99 - UNINCORPORATED AREA APN: <br /> BOS District SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0024245 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CHEVRON ENVIRONMENTAL MGMT CO (Circle One) <br /> Account Balance as of 8/25/2003: $0.00 <br /> (Circle_One) <br /> Transfer to Acti Inactve j <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? late <br /> 2950-ENVIRON ASSESS PR0519076 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to b�TR(aNSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANS ERED: '$155.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> RENS: Date Account out: 2 Date <br /> COMMENTS: <br /> \\Phs-ehsql-nt\apps\Envisions\Reports\5021.rpt <br />