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Run by SANDY <br /> SaOIJoaquin County PHS/EHD � Report #5021 <br /> FACILITY INFORMATION as of 11/26/96 <br /> - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> Make changes/corrections in RED pen or pencil: <br /> OWNER FILE INFORMATION INFORMATION CHANGE (date): <br /> OWNERSHIP CHANGE (date): <br /> OWNER ID: 000721 New Owner ID: OO <br /> owner Name: SOUTHLAND CORPORATION <br /> Owner DBA: 7 ELEVEN <br /> Owner Address: 5820 STONERIDGE MALL RD, #310 <br /> PLEASANTON, CA 94588 <br /> Home Phone: 209-239-3252 <br /> Soc Sec# / Tax ID#: <br /> Ownership Type: O1 CORPORATION <br /> Mailing Address: PO BOX 404 <br /> care of: SOUTHLAND CORPORATION �� p <br /> PLEASANTON, CA 94588 �(k� ( S l -1 X MDR <br /> FACILITY FILE INFORMATION <br /> FACILITY ID: 005693 <br /> Facility Name: 7 ELEVEN STORE* <br /> Location: 9110 THORNTON RD <br /> STOCKTON 95209 <br /> Phone; <br /> Mailing Address: 655 UNIVERSITY AVE SUITE 104 <br /> care of: SOUTHLAND CORPORATION <br /> SACRAMENTO, CA 95819 <br /> Location Code: 0 1 APN: <br /> BOS District: 003 SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUNT ID: 0008440 New Account ID: 000 <br /> Mail Invoices to: Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name: SOUTHLAND CORPORATION (Circle one) <br /> Account Balance as of 11/26/96 : $0 . 00 (Circle one) <br /> Record UST(s) Transfer to Activate / Inactivate <br /> P/E Description ID Employee Status Linked new owner? Delete <br /> _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - - - - - - - - - <br /> _ - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - <br /> 2381 UST FACILITY (BEFORE 1/84) PR503130 041 KITH - - - _ -INACTIVE- 3 Y N A I D <br /> _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, acknowledge that all site and/or <br /> project specific PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the <br /> BILLING PARTY on this form. I also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN <br /> COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ <br /> _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ <br /> PR Records to be TRANSFERED: x $20.00 = Amount Paid Date <br /> Water System to be TRANSFERED: x $150.00 = Amount Paid Date <br /> Payment Type Check # Recvd by <br /> REHS or COUNTER SUPV Date_/_/_ ACCT out: Date/ / UNIT/File:_/_/_ <br />