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Date run ' 8/21/2015 3:46:38PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 8/21/2015 Record Selection Criteria: Facility ID FA0020646 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) OWNER FILE INFORMATION Number of facilities for this owner: 1 Owner ID OW0016968 Owner Name SUPERLUBE PLUS INC Owner DBA TRACY, CA 95376 Owner Address 5023 GRAY HAWK LN Mailing Address DUBLIN, CA 94568 Home Phone 925-785-5443 Work/Business Phone 209-836-3602 Mailing Address 5023 GRAY HAWK LN BOS District DUBLIN, CA 94568 Care of TRUONG, MINH FACILITY FILE INFORMATION Facility ID / CERS ID FA0020646 10187655 Facility Name SUPERLUBE PLUS INC Location 1170 LINCOLN BLVD TRACY, CA 95376 Phone 925-785-5443 Mailing Address 1170 LINCOLN BLVD TRACY, CA 95376 Care of TRUONG, MINH Location Code 03 -TRACY BOS District 005 - ELLIOTT, BOB APN 23228021 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name MINH TRUONG Title OWNER Day Phone 925-785-5443 Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0037000 Mail Invoices to Facility Account Name SUPERLUBE PLUS INC Account Balance as of 8/21/2015: $0.00 SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail : Mail Invoices to: New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1616 - RETAIL MARKET < 1000 SO FT W / FOOD PREP PR0535928 EE0001420 - MELISSA NISSIM Inactive Y N A I D 2227 - GEN 5<25 TONS PERMIT PR0535857 EE0002646 - THUY TRAN Active Y N A I D 2332 - EXEMPT TANK FACILITY PR0535856 EE0002646 - THUY TRAN Active,l Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PRO535858 Inactive Y N A I D 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 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 Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS: * $25.00 = Date Date Amount Paid Date _ Amount Paid Date Received by Account out: Date / Invoice #: