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Date run 7/22/2015 9:33:14AN SA*AQUIN COUNTY ENVIRONMENTAL _ TH DEPARTMENT Report#5021 Run by Paget Facility Information as of 7/22/2015 Record Selection Criteria: Facility ID FA0003712 Make changes/corrections in RED ink. INFORMATION CHANGE(date) OWNERSHIP CHANGE(date) OWNER FILE INFORMATION Number of facilities for this owner: 27 SSN I Fed Tax ID Owner ID OW0001987 New Owner ID Owner Name CHEVRON PRODUCTS COMPANY(A DIVISI Owner DBA Owner Address 8001 BOLLINGER CANYON RD SAN RAMON,.CA 94583 Home Phone 925_842-9002 Work/Business Phone 925_842-9002 Mailing Address P.O. BOX 6004,ATTN: PERMIT DESK SAN RAMON, CA 94583 Care of PERMIT DESK FACILITY FILE INFORMATION Site Mitigation Facility .. 7- Facility ID/CERS ID FA0003712 10181335 Site Mitigation Facility Facility Name CHEVRON STATION#94275' Location 2905 W BENJAMIN HOLT DR STOCKTON, CA 95207 Phone 209-478-5555 x Mailing Address P.O. BOX 6004,ATTN: PERMIT DESK SAN RAMON, CA 94583 Care of CHEVRON STATION #9427511705 Location Code 01 -STOCKTON Alt Phone BOS District Q02 - MILLER, KATHERINE Fax APN 09760004 Entail: EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0003291 New Account ID: Mail Invoices to Account Mail Invoices to: Owner / Facility ! Account Account Name CHEVRON PRODUCTS COMPANY (A DIVISION OF (Circle One) Account Balance as of 7/2212015: $-104.00 (Circle One) Transferto Activellnactve Program/Element and Description Record ID Employee ID and Name Status New owner? Delete 1921 -HMBP-Reqular-Primary Location PRO519641 EE0000006-HAZA SAEED Active Y N A I D 2220-SM HW GEN<5 TONSNR PR0517536 EE0000005-FATINAH ZAREEF Active Y N A 1 D 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511745 EE0000000-HAZ MAT SJC 0 E Inactive Y N A I D 2301 -UST STATE SURCHARGE FEE PR0507725 EE0000418-MICHAEL KITH Inactive Y N A I D 2351 -UST FACILITY-2481 COMPLIANT PR0231952 EE0000005-FATINAH ZAREEF Active Y N A I D 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0507414 EE0000418-MICHAEL KITH Inactive Y N A I D ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0532364 Inactive Y N A 1 0 BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project speck,PHSrEHD hourly charges associated with this 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 ordinance Codes and+or Standards and State and+or Federal Laws. APPLICANTS SIGNATURE: Date I / Program Records to be TRANSFERED: *$25.00= Amount Paid Date ! 1 Water System to be TRANSFERED: Amount Paid Date 1 / Payment Type Check Number Received by EHD Staff: Date I 1 Account out: Date 1 1 COMMENTS: Invoice#: