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Date run 7/26/2018 11:02:30Ar SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/26/2018 <br /> Record Selection Criteria: Facility ID FA0006439 <br /> Make changesicorrections in RED ink. _ p <br /> INFORMATION CHANGE(date) 2 /6 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br /> Owner ID OW0013503 New Owner ID <br /> Owner Name California Fuel Supply <br /> Owner DBA COUNTRY CLUB MOBIL CIRCLE K <br /> OwnerAddress 587 YGNACIO VALLEY RD <br /> WALNUT CREEK, CA 94596 <br /> Home Phone 415-516-7676 <br /> Work/Business Phone 925-979-0560 <br /> Mailing Address 587 Ygnacio Valley Road <br /> Walnut Creek, CA 94596 <br /> Care of MIKE AHMADI, PRESIDENT <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID/CERS ID FA0006439 10118074 <br /> Facility Name IRGBHNTRY CLUB VALERO c" ✓u c I„_,I f-I 6,t): ( <br /> Location 2575 COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204 <br /> Phone 209-932-1307 x <br /> Mailing Address 587 Ygnacio Valley Road <br /> Walnut Creek, CA 94596 <br /> Care of California Fuel Supply <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0008426 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Country Club Mobil Circle K (Circle One) <br /> Account Balance as of 7/26/2018: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO519887 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0514045 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512103 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2301 -UST STATE SURCHARGE FEE PRO507710 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> 2351 -UST FACILITY-2481 COMPLIANT PR0231070 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0507628 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0532925 Inactive Y N 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 <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date <br /> Water System to be_T ANSFERED: Amount Paid Date <br /> Payment Type Check Number Received y <br /> EHD Staff: tk`= Date l T` l / Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />