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Date run 7/26/2018 11:02:30Ar SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 7/26/2018 <br />Record Selection Criteria: Facility ID FA0006439 <br />Make changesicorrections in RED ink. _ p <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />OWNER FILE INFORMATION Number of facilities for this owner <br />: 2 SSN / Fed Tax ID <br />Owner ID OW0013503 <br />New Owner ID <br />Owner Name California Fuel Supply <br />Owner DBA COUNTRY CLUB MOBIL CIRCLE K <br />OwnerAddress 587 YGNACIO VALLEY RD <br />WALNUT CREEK, CA 94596 <br />Home Phone 415-516-7676 <br />Work/Business Phone 925-979-0560 <br />Mailing Address 587 Ygnacio Valley Road <br />Walnut Creek, CA 94596 <br />Care of MIKE AHMADI, PRESIDENT <br />FACILITY FILE INFORMATION <br />Site Mitigation Facility <br />Facility ID / CERS ID FA0006439 10118074 <br />Facility Name IRGGHNTRY CLUB VALERO <br />(1� n s C 1,k_� r't c4) I C; r c I <br />Location 2575 COUNTRY CLUB BLVD <br />STOCKTON, CA 95204 <br />Phone 209-932-1307 x <br />Mailing Address 587 Ygnacio Valley Road <br />Walnut Creek, CA 94596 <br />Care of California Fuel Supply <br />Location Code 01 - STOCKTON <br />Alt Phone <br />BOS District 001 - VILLAPUDUA, CARLOS <br />Fax <br />APN <br />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 AR0008426 <br />New Account ID: <br />Mail Invoices to Account <br />Mail Invoices to: Owner / Facility / Account <br />Account Name Country Club Mobil Circle K <br />(Circle One) <br />Account Balance as of 7/26/2018: $0.00 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID <br />Employee ID and Name Status New Owner? Delete <br />1920 - HMBP-Common Materials PRO519887 <br />EE0009817 - ROBERT LOPEZ Active Y N A I D <br />2220 - SM HW GEN <5 TONS/YR PR0514045 <br />EE0001421 - STACY RIVERA Active Y N A I D <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512103 <br />EE0000000 - HAZ MAT SJC OES Inactive Y N A I D <br />2301 - UST STATE SURCHARGE FEE PRO507710 <br />EE0000418 - MICHAEL KITH Inactive Y N A I D <br />2351 - UST FACILITY - 2481 COMPLIANT PR0231070 <br />EE0001421 - STACY RIVERA Active Y N A I D <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0507628 <br />EE0000418 - MICHAEL KITH Inactive Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGI PR0532925 <br />Inactive 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 facility <br />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 <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />Program Records to be TRANSFERED: * $25.00 = <br />Amount Paid Date <br />Water System to be_TRANSFERED: <br />Amount Paid Date <br />Payment TypeG Check Number <br />Received y14 <br />EHD Staff: L tF>`= i Z Date l - ` l / Account out: Date <br />COMMENTS: <br />Invoice #: <br />