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Daterun ;3/24/2015 1;FaciRy <br /> 1 SAN JOAQUIiN COUNTY ENVIRONMENTAL HEALTH DEPARTMENTRun by Report#5021 <br /> Facility Information aS of 312412015 Pagel <br /> Record SeleCriteria, FA0003738 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE (date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner : 1 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 ID/CERS ID FA0003738 10181363 <br /> Facility Name CHARTER WAY SHELL* <br /> Location 620 W CHARTER WAY o r r <br /> STOCKTON. CA 95206 <br /> Phone 209-466-1901 x <br /> Mailing Address 620 W CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Care of SUKHI SINGH <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 - VILLAPUDUA, CARLOS 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 Invoices to Account Maid Invoices to: Owner f Facility 1 Account <br /> Account Name CHARTER WAY SHELL* (Circle One) <br /> Account Balance as of 3/24/2015: $0 00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Prograin/Element and Description Record ID Empioyee ID and Name Status New Owner? Delete <br /> 1615-RETAIL MKT 301-2000 SQ FT(PREPKGDILTD 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 TONS/YR PR0518093 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO512161 EE0000000-HAZ MAT SJC OES Inactiv* Y N A 1 D <br /> 2361 -UST FACILITY PR0231058 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2399-UNIRED PROGRAM FAC STATE SURCHARGE F PRO507428 FE0000451 -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 ad site,andfor 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 anelor Standards and State andtor <br /> Federal Laws <br /> APPLICANT'S SIGNATURE. Date ! 1 <br /> Program Records to be TRANSFERED $25.00= Amount Paid Date ! 1 <br /> Water System to be TRANSFERED: Amount Paid Date !' / <br /> Payment Type Check Number Received by <br /> REHS: ,. Date '_�3 I f2 1 Account out: C`�— Date 1 y l� <br /> COMMENTS: <br />