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Date run "`3/29/2016 11:22:09AI SAN JO1W COUNTY ENVIRONMENTAL HEAL EPARTMENT <br /> Run by Report#5027 <br /> Facility Information as of 3/29/2016 Pagel <br /> Record Selection Criteria: Facility ID FA0003720 <br /> Make changes/corrections In RED ink. <br /> INFORMATION CHANGE(date) 'OX <br /> OWNERSHIP CHANGE(date) D3J 2 (O <br /> OWNER FILE INFORMATION Number of facilities for this owner: 5 SSN/Fed Tax ID : . <br /> Owner ID OW0006297 New Owner ID <br /> Owner Name SAINT, SURINDER SINGH �iAV//1/Dp /I11G1/f <br /> Owner DBA Cffn.N7E�C e.,,tY CHFUKsti <br /> Owner Address 14836 HARBOR CT <br /> LATHROP, CA 95303 <br /> Home Phone 209-992-1735 <br /> Work/Business Phone 209-992-1735 <br /> Mailing Address 14823 HARBOR CT _/4236 yyq go <br /> LATHROP, CA 95303 L,9jtiQ Cy gig <br /> Care of RAVINDER SINGH <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility lD/CERS ID FA0003720 10181345 <br /> Facility Name CHEVRON #92033' G z/AF?EL wA✓ /sffi�t"a�7/ <br /> Location 508 W DR MARTIN LUTHER KING JR BLV <br /> Stockton, CA 95206 <br /> Phone 209-465-3440 x <br /> Mailing Address 508 W CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Care of SURINDER SINGH SAINI .1?i91/jJliDlz z' g/Iya,y <br /> Location Code 01 -STOCKTON Alt Phone 209- 952^/�?3.f <br /> BOB District 001 -VILLAPUDUA, CARLOS Fax 2a$- X62- 0S-41 <br /> APN 16504016 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name 'RAV I Al 511tJG.F4 <br /> Title OWN 1i <br /> Day Phone 209 942- ! <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> AccountlD AR0003299 R�((Y'+M1�1,,N�nnrNewAccountID: <br /> Mail Invoices to Account MaII19WI�sY6 Owner / Facility Account <br /> Account Name CHEVRON#92033 MAR'29Z�;u rcleone <br /> Account Balance as of 3/29/2016: $0.00 <br /> SA ENV <br /> COUNTY (Circle One) <br /> Program/Element and Description Record ID Employee 10 and AULTH DEP RTIMENTAWU Status Transfer to Active/InacNe <br /> ARTIyENT New Owner! Delete <br /> 1921 -HMBP-Regular-Primary Location PRO521197 EE0009817-ROBERT LOPEZ Active N I D <br /> 2220-SM HW GEN<5 TONSNR PR0518549 EE0001421 -STACY RIVERA Active N I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO618849 EE0000000-HAZ MAT SJC OES Inactive N A I D <br /> 2301 -UST STATE SURCHARGE FEE PRO507757 EE0000451 -STEVE SASSON Inactive N A I D <br /> 2361 -UST FACILITY PR0231057 EE0001421 -STACY RIVERA Active 1�' N c' I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO507420 EE0002670-MUNIAPPA NAIDU Inactive Y N FC I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534556 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,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the party identHied as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andror Standards and State and/or <br /> Federal Laws, <br /> APPLICANT'S SIGNATURE: Date ,3 125 //6 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid_'-Date 3 / <br /> Water System to bT NSFERED: Amount Paid Date / / <br /> Payment Type Sty. Check Number 3 6:51-2 Received by <br /> EHD Staff: Date /!! / X Account out: Date <br /> COMMENTS: Invoice*279 39 <br /> t' <br />