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Date run 10/31/2013 10:57:35/ SAN JC UIN COUNTY ENVIRONMENTAL HEA i DEPARTMENT Report x5021 <br /> Run by <br /> Facility Information as of 10/31/2013 Pagel <br /> Record Selection Criteria: Facility ID FA0003738 <br /> Make changes/corrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID 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 lD/CERS ID FA0003738 10,181,363 <br /> Facility Name CHARTER WAY SHELL' <br /> Location 620 W DR MARTIN LUTHER KING JR BLVD <br /> STOCKTON, CA 95206-1710 <br /> Phone 209-466-1601 <br /> Mailing Address 620 W DR MARTIN LUTHER KING JR BLVD <br /> STOCKTON, CA 95206-1710 <br /> Care of 620 WEST CHARTER WAY LLC <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 16504007 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name 620 WEST CHARTER WAY LLC <br /> Title <br /> Day Phone 209-466-1601 <br /> Night Phone 415-999-0714 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003317 New Account ID: <br /> Mail lnvoicesto Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name CHARTER WAY SHELL' (CirdeOne) <br /> Account Balance as of 10/31/2013: $-125.00 <br /> (Circle One) <br /> Transferto ActivMnactve <br /> Prograns Element and Description Record ID Employee ID and Name Status 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 TONSNR PR0518093 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512161 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2361 -UST FACILITY PR0231068 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 PRO533325 Inactive 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,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 andor Standards and State andor <br /> Federal Laws. <br /> APPLICANTS 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 /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />