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udlo run 1!2412005 3:06:01-PN SAN JOA 1N COUNTY ENVIRONMENTAL HEALk4DEPARTMENT Report 95021 <br /> "_o,•by Pagel <br /> Facility information as of 1 12 412 0 0 5 <br /> il—ord Selection Criteria: Facility ID FA0015314 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0000153 New Owner ID <br /> Owner Name CIRCLE K STORES INC I <br /> Owner DBA CONOCOPHILLIPS COMPANY <br /> Owner Address PO BOX 52085 <br /> PHOENIX, AZ 850722085 <br /> Home Phone Not Specified <br /> Work/Business Phone 209.-473-7337 � <br /> Mailing Address 600 N DAIRY ASHFORD TR 10326 <br /> HOUSTON, TX 77079 <br /> Care of LICENSE & PERMITS <br /> t-ACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0015314 <br /> Facility Name CIRCLE K STORE <br /> Location 7647 PACIFIC AVE <br /> STOCKTON, CA 95217 j <br /> Phone <br /> Mailing Address PO BOX 52085 ' <br /> PHOENIX, AZ 850722085 <br /> Care of CIRCLE K <br /> Location Code 01 -STOCKTON APN:07748014 <br /> BOS District SIC Code: <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 G-- (Circle one) <br /> Aucount Balance as of 1/24120 $-158.10 <br /> (Gird I <br /> Transfer to Activ llneclVe <br /> New Owner? Del;e <br /> -rcrgram/Elemenl and Description Record 11) Employee ID and Name talus , <br /> 2950-ENVIRON ASSESS PRO522493 EE0000684-MICHAEL 1NFURNA :A�c'K'� e YN A 1D <br /> nil LING and COMPLIANCEACKNOWLEDGEMENT•. I,the undersigned owner,operator or agent of same,acknowledge that all site,and! poject specific.PHSIFHD hourly charges associated with this ,I <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 and/or Standards and <br /> and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / 1 <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date 1 ! <br /> vtf•lter System to be T SFERED: *$155.00= Amount Paid Date—1—/ <br /> Payment T Check Number Received by <br /> ,.JHS: - Date / ! Account out: Date / ! <br /> --alMENTS: D <br />