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Dale run 3/24/2015 11:08:O6A1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Run by Report A5021 <br /> Facility Information as of 3/24/2015 Pagel <br /> Record Seledion Cmem, Facility ID FA0003738 <br /> Make changes/corrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID <br /> OW0014416 New Owner ID <br /> Owner Name 620 WEST CHARTER WAY LLC <br /> Owner DBA CHARTER WAY SHELL <br /> Owner Address 630 SYLVAN AVE <br /> SAN MATEO, CA 94403 <br /> Home Phone 415-999-0714 <br /> Work/Business Phone 209-466-1901 <br /> Mailing Address 630 SYLVAN AVE <br /> SAN MATEO, CA 94403 <br /> Care of SHIVDEV SINGH TURK <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID/CERS ID FA0003738 10181363 <br /> Facility Name CHARTER WAY SHELL* <br /> Location 620 W CHARTER WAY <br /> STOCKTON, CA 95206 g � <br /> Phone 209-466-1901 x <br /> Mailing Address 620 W CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Care of SUKHISINGH <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 16504007 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name 620 WEST CHARTER WAY LLC <br /> Title <br /> Day Phone 209466-1601 <br /> Night Phone 415-999-0714 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003317 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name CHARTER WAY SHELL` (Circle One) <br /> Account Balance as of 3/24/2015: $0.00 <br /> (Circle One) <br /> Progra"Element and Description Rawrtl ID Employee ID antl Nama Status Transfer to Active/lnactve <br /> New OwneR Delete <br /> 1615-RETAIL MKT 301-2000 SO FT(PREPKGD/LTD PF PRO161209 EE0008999-LEYNA HUYNH Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PRO519929 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0518093 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512161 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2361-UST FACILITY PR0231058 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO507428 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533325 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,eolmovdedge that all site,anctor project specific,PHSrEHD hourly charges asecciatW with this facility <br /> or activity will be billed to the pony identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State anclor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: , Date �3 Account out: —awit Date <br /> COMMENTS: <br />