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Date run 1024/2013 11:47:35/ SAN J( JIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021pagel <br /> Run by <br /> Facility Information as of 10124/20 <br /> Record Selection Cmena: Facility ID FA0001817 <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 OW0000721 New Owner ID <br /> Owner Name 7- ELEVEN INC <br /> Owner DBA 7-ELEVEN <br /> Owner Address 2711 N HASKELL AVE <br /> DALLAS, TX 75204 <br /> Home Phone Not Specified <br /> Work/Business Phone 208-429-8466 <br /> Mailing Address PO BOX 219088 <br /> DALLAS, TX 752219088 <br /> Care of ATTN: LICENSE DEPT 274L <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility lD/CERS ID FA0001817 10,166,191 <br /> Facility Name 7-ELEVEN #2369-35355 <br /> Location 3202 W HAMMER LN <br /> STOCKTON, CA 95209 <br /> Phone 209-957-2900 <br /> Mailing Address PO BOX 219088 <br /> DALLAS, TX 75221 <br /> Care of LICENSING <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 08232010 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SANAYE WALKER <br /> Title FIELD CONSULTANT <br /> Day Phone 209-957-2900 <br /> Night Phone 925-998-0594 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0001821 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner I Facility / Account <br /> Account Name 7-ELEVEN #2369-35355 CircleOne) <br /> Account Balance as of 10/24/2013: $0.00Ot^' <br /> G � _/QV1 (Circle One) <br /> V- Transfer to AdivellnacNe <br /> Progr "Element and Description Record ID Employee ID and Name 6� D Status New Owner? Delete <br /> 1615-RETAIL MKT 301-2000 SO FT(PREPKGD/LTD PF PRO160263 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> TLffZ - MBP-Regular-Primary Location PR0519486 EEOOOOOOO-HAZ MAT SJC OE Inactive Y N ® 1 D <br /> 2220-SM HW GEN<5 TONS/YR PR0518105 EE0004636-GARRETT BACKUS Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511529 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2301 -UST STATE SURCHARGE FEE PRO508186 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2361 -UST FACILITY PR0231129 EE0004636-GARRETT BACKUS Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0507284 EE0000418-MICHAEL KITH Inactive Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532525 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 prolad 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 /> 11 <br /> APPLICANT'S'17 <br /> GNATURE: 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 Account out: GATN Date /0 2-S—/ 1.3 <br /> COMMENTS: "0G lxG c-.,,,AM ao7- /+,a,rr— 3 <br />