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Date run ✓3/29/2016 11:22:09AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Run by <br />Facility Information as of 3/29/2016 <br />Report 95021 <br />Pagel <br />Record Selection Criteria: Facility ID <br />FA0003720 <br />2220 - SM HW GEN <5 TONSNR <br />PR0518549 <br />EE0001421 - STACY RIVERA <br />Active <br />Make changes/corrections in RED ink. <br />'0 Z" <br />"1 <br />EE0000000 - HAZ MAT SJC OES <br />Inactive <br />INFORMATION CHANGE (date) <br />1 <br />EE0000451 - STEVE SASSON <br />Inactive <br />OWNERSHIP CHANGE (date) <br />PR0231057 <br />OWNER FILE INFORMATION <br />Number of facilities for this owner: 5 <br />SSN/Fed Tax ID :_ <br />PR0507420 <br />Owner ID <br />OW0006297 <br />New Owner ID <br />PRO534556 <br />Owner Name <br />SAINI, SURINDER SINGH <br />Owner DBA <br />G'f�i9c'iF.0 .ty CiyFy='rte./ <br />Owner Address <br />14836 HARBOR CT <br />LATHROP, CA 95303 <br />Home Phone <br />209-992-1735 <br />Work/Business Phone <br />209-9.92-1735 <br />10 7 - �iGS'-3y iia <br />Mailing Address <br />14823 HARBOR CT <br />LATHROP, CA 95303 <br />Li9i/�e�i� Cts 9S' 33a <br />Care of <br />RAVINDER SINGH <br />FACILITY FILE INFORMATION <br />Site Mitigation Facility <br />Facility ID / CERS ID <br />FA0003720 10181345 <br />Facility Name <br />CHEVRON #92033* <br />Location <br />508 W DR MARTIN LUTHER KING JR BLV <br />Stockton, CA 95206 <br />Phone <br />209-465-3440 x <br />Mailing Address <br />508 W CHARTER WAY <br />STOCKTON, CA 95206 <br />Care of <br />SURINDER SINGH SAINI <br />Location Code <br />01 - STOCKTON <br />Alt Phone Zd g- 99,2 - /;73,5" <br />BOS District <br />001 - VILLAPUDUA, CARLOS <br />Fax 269- -762- 6'9S"y <br />APN <br />16504016 <br />EMail: <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />'R AV 1 N DI'E. 5nu6- 4 <br />Title <br />0 Lo N <br />Day Phone <br />919 2-- ! !> <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0003299 <br />Mail Invoices to Account <br />Account Name CHEVRON #92033* <br />Account Balance as of 3/29/2016: $0.00 <br />Program/Element and Description <br />PAYMENT <br />New (('' tt ���^yNew Account ID: <br />MtITn§I'cVs'rbD Owner <br />/e)Account <br />MAR'2 9 ti <br /><Ci�' <br />SA ENO QUIN COUNTY <br />� ENTAL <br />Record ID Employee ID and Na LTH DEPAR-rMCNI . Status <br />1921 - HMBP-Regular-Primary Location <br />PR0521197 <br />EE0009817 - ROBERT LOPEZ <br />Active <br />2220 - SM HW GEN <5 TONSNR <br />PR0518549 <br />EE0001421 - STACY RIVERA <br />Active <br />2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION <br />PR0518849 <br />EE0000000 - HAZ MAT SJC OES <br />Inactive <br />2301 - UST STATE SURCHARGE FEE <br />PRO507757 <br />EE0000451 - STEVE SASSON <br />Inactive <br />2361 - UST FACILITY <br />PR0231057 <br />EE0001421 - STACY RIVERA <br />Active <br />2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F <br />PR0507420 <br />EE0002670 - MUNIAPPA NAIDU <br />Inactive <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG <br />PRO534556 <br />Inactive <br />Transferto <br />New Owner? <br />N <br />N <br />N <br />N <br />Y N <br />Y N <br />Y N <br />(Circle One) <br />Active/Inactve <br />Delete <br />I D <br />I D <br />A I D <br />A I D <br />I D <br />I D <br />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: Date j 125 <br />Program Records to be TRANSFERED: ` $25.00 = Amount Paid—Date 3 / z a / <br />Water System to bT ANSFERED: Amount Paid Date <br />Payment Type S' - Check Number 3 G �J 1 % Received by <br />EHD Staff: / i Date ? / Account out: Date 5/__50/ 16, <br />COMMENTS: Jt, ��� n_3 /nomn e -t -F r/frr/�(� Invoice#:oc7qJO <br />