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Date run 10/19/2010 10:09:111 SAN 307 'IN COUNTY ENVIRONMENTAL HEAT ^ DEPARTMENT Report#5021 <br /> Run by low Pagel <br /> Facility Information as of 10/19/20141' <br /> Record Selection Cntena: Facility ID FA0015314 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> SSN!Fed Tax ID <br /> Owner ID OW0014604 New Owner ID <br /> Owner Name BEST CALIF GAS LTD TOSCO TRUST <br /> Owner DBA CIRCLE K <br /> Owner Address <br /> Home Phone 602-728-8000 <br /> Work/Business Phone 209-952-4515 <br /> Mailing Address PO BOX 52085 <br /> PHOENIX,AZ 85072 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0015314 <br /> Facility Name CIRCLE K <br /> Location 7647 PACIFIC AVE <br /> STOCKTON, CA 95217 <br /> Phone 209-952-4515 <br /> Mailing Address PO BOX 52085 <br /> PHOENIX, AZ 850722085 <br /> Care of CIRCLE K <br /> Location Code 01 -STOCKTON Alt Phone <br /> Bos District 002 - RUHSTALLER, LARRY Fax <br /> APN 07748014 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name CIRCLE K <br /> Title <br /> Day Phone 209-952-4515 <br /> Night Phone 602-728-8000 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026362 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility I Account <br /> Account Name TERRA VAC (circle one) <br /> Account Balance as of 10/19/20`10: $0.00 <br /> (Circle One) <br /> Transfer to Activellnacive <br /> ProgramlEle nt and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 0-ENVIRON ASSESS PR0522493 EE0000684-MICHAEL INFURNA Ac' Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andt r project specific,PHSIEHD hourly charges associated with this <br /> 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 Ordinate Codes andtor Standards and <br /> State andlor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I 1 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date ! / <br /> Water Syste T NSFERED: Amount Paid Date / ! <br /> Payment Tye Check Number _ _Received by <br /> REHS: Date ! 1 Account out: Date O <br /> COMMENTS: <br /> l� <br /> Ileh-envlenvisi onlreports15021.rpt <br />