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Date run 12/22/2014 10:48:19/ SAN JO elle1N COUNTY ENVIRONMENTAL HIEAI\� DEPARTMENT Reporttt5021 <br /> Run By Pagel <br /> Facility Information as of 12/22/2014 <br /> Record Selection Criteria: Facility ID FA0003602 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 12 SSN/Fed Tax ID <br /> Owner ID OW0002829 New Owner lD <br /> Owner Name TESORO SIERRA PROPERTIES LLC <br /> Owner DBA <br /> Owner Address 19100 RIDGEWOOD PKWY <br /> SAN ANTONIO, TX 78259 <br /> Home Phone 818-577-2663 <br /> Work/Business Phone 210-626-4994 <br /> Mailing Address RETAIL ENVIRONMENTAL: 19100 RIDGEW( <br /> SAN ANTONIO, TX 78259 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID/CERS ID FA0003602 10181229 Site Mitigation Facility <br /> Facility Name TESORO/SHELL 68151 w <br /> Location 35 N CHEROKEE LN <br /> LODI, CA 95240 <br /> Phone 209-369-1525 x <br /> Mailing Address 19100 RIDGEWOOD PKWY MS: TX1-022 <br /> SAN ANTONIO, TX 78259 <br /> care of Tesoro West Coast Company LLC <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 04318003 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003180 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name TESORO SIERRA PROPERTIES LLC (Circle One) <br /> Account Balance as of 12/22/2014: $-25.00 <br /> (Circle One) <br /> Transfer to Active/Ince <br /> PrograMElement and Description Record ID Employee ID and Name status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0521233 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO518325 EE0001422-ARIS VELOSO Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO511303 EE0000000-HAZ MAT SJC DES Inactivr Y N A I D <br /> 2301 -UST STATE SURCHARGE FEE PRO515543 EE0002670-MUNIAPPA NAIDU Inactivf Y N A I D <br /> 2361-UST FACILITY PR0231320 EE0001422-ARIS VELOSO Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0506654 EE0002670-MUNIAPPA NAIDU Inactiv( Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532447 Inactivt Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific.PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also certity that all operations will be performed in accordance with all applicable Ordinance Codes andior Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / I <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> RENS: Date_/ / Account out: Date <br /> COMMENTS: <br />