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05/21/2007 09:39 2094640�8 ENVIRONMENTAL HEAT H PAGE 07/08 <br /> Dalcrua 5/212007 9:17:20M SAN JO .r IN COUNTY ENVIRONMENTAL HEALT PARTMENT Report aso21 <br /> Rents 4008 Papel <br /> Facility Information as of 5/21/2007 <br /> Record Selo mCmeft FedXry to FAD002M <br /> Make changestcorreetlons in RED R V <br /> ED <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE{defd `. <br /> OWNER FILE INFORMATION DAN JUAUUIN GUUNIY <br /> OwnerlD OW0011025 New OwnerlD : OFFICE OF EMERGENCY SERVICES <br /> Owner Name USA PETROLEUM CO T scpc StLI212tk �ld> EFS ESQ <br /> Owner DBA USA PETROLEUM CO LLC <br /> Owner Address 905 RANCHO CONEJO BLVD -34-Sen S• 3 44111 '� <br /> NEWBURY PARK, CA 913201716 AVBURN U•ta • 9'Eclo - i <br /> Home Phone 805-214-9200 'tib - %Ica <br /> Work/BusinessPhone 805-214-0925 254 85b $Zo° <br /> Mailing Address 905 RANCHO CONEJO BLVD 3QFd t90W,':W- 241 <br /> NEWBURY PARK, CA 913201716 msugh1 `1`$001 — 5911 <br /> Care of DIAZ,CATHY QtJN <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility 10 PA0002048 <br /> Facility Name USA GASOLINE#836 USA (Q A& :!-PCT Tb19-1 <br /> Location 2705 COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204 <br /> Phone 209.4654756 (P*3) S96 - 8700 <br /> Mailing Address 905 RANCHO CONEJO BLVD ;z 4Sri' S - `3 gh14 got <br /> NEWBURY PARK, CA 913201716 _AU— Bll�R `Vib C�c I- UV6( <br /> Care of DIAZ, CATHY <br /> Location Code 01 -STOCKTON APN:12121008 <br /> 1305 District 003-MOW,VICTOR SIC Code:9900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> account ID AR0003410 New Account ID: <br /> Mall Invoices to Facility Mall Invoices to: Owner ! Facility I Account <br /> Account Name USA GASOLINE#835 0� <br /> Account Balance as of 5/2112007: $0.00 <br /> Tramoor to dG One) <br /> Adhmnnadva <br /> Progra,J@Mmml and Desorption Record to Empbyee lO and Name status New Omer? Delete <br /> 1614-FOOD EST>l001 SO FT W/O SEATING PR0163086 EED000149-RAYMOND BORGES Active Y N A I D <br /> 2220-SM HW GEN e5 TONS/YR PRO518421 EE0008317-RAYMOND VON FLUE Active Y N A 1 0 <br /> 2224.HAZ MAT BUSINESS PLAN AIITHORIZATIOIPR0513218 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PRO520556 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2301 UST STATE SURCHARGE FEE PRO515539 EE000D418-MICHAEL KITH Inactive Y N A 1 0 <br /> 2361-UST FACILITY PR0231072 EE0008317-RAYMOND VON FLUE Active Y N A 1 D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARIPRO507290 EED000418-MICHAEL KITH Inactive Y N A I D <br /> at W Nc and COMPDANCE ACKNOWLEJDEMEW: 1.Me undeNgnsd dwsor,operator or agent of same,a Mowtedge tried all eke,and/or ptuied 2Pocam,PHVEHD horny ct arpat associatedwah aka <br /> W^or amlulty wR be bled to km party scennneo as the OWNER on ft form. I also o"N that all uperakons ora m perrotmed In accordance wxh all applkatde OrMece Cade$anger Stnndama and <br /> Stale aWor Federel Laws. <br /> A <br /> APPLICANTS SIGNATURE: - Date S,�! <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System t0 be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type check Number Received by <br /> RENS: Date_J_l_ Account out: Date <br /> COMMENTS' <br /> ;K 15.�yo.0o — �A� -P 85 22`[5m/o <br /> 11ph4ehsgl-ntlappslerwislo nslreporfsUr021.rpt <br />