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Date nm 12!2612012 9:56:30A SAN JO. AN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by 4`f "'' Pagel <br /> Facility Information as of 1212612012 <br /> Record Selection Criteria: Facility ID FA0007491 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0005013 New Owner ID <br /> Owner Name VALLEY PACIFIC PETROLEUM SERVICES <br /> Owner DBA <br /> Owner Address 166 A FRANK WEST CIR <br /> STOCKTON, CA 95206 <br /> Home Phone 209-948-9412 <br /> Work/Business Phone 209-993-8793 <br /> Mailing Address 166 FRANK WEST CIR <br /> STOCKTON, CA 95206 <br /> Care of VALLEY PACIFIC PETROLEUM SERV <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0007491 <br /> Facility Name VALLEY PACIFIC FRESNO AVE CARDLOCK <br /> Location 1524 FRESNO AVE <br /> STOCKTON, CA 95206 <br /> Phone 209-948-9412 <br /> Mailing Address 166 FRANK WEST CIRCLE <br /> STOCKTON, CA 95206 <br /> Care of ELIASON, MIKE <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 16337025 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR001 1647 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility ! Account <br /> Account Name VALLEY PACIFIC FRESNO AVE CARDLOCK (Circle one) <br /> Account Balance as of 12/26/2012: $25.00 <br /> (Circle One) <br /> Transfer to Activellnaclve <br /> ProgramrElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1926-HMBP-Unstaffed Network Location PR0521 D56 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN =5 TONS/YR PR0518517 FE0001421 -STACY RIVERA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHOR I7ATIOrPRO513176 EE0000000-HAZ MAT SJC OES Inactive Y N A i D <br /> 2301 -UST STATE SURCHARGE FEE PR0516168 EE0002670-MUNIAPPA NAIDU Inactive Y N A I D <br /> 2361 -UST FACILITY PR0506545 EE0001421 -STACY RIVERA Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PR0507670 EE000267C-MUNIAPPA NAIDU Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0533714 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I.the undersigned owner,operator or agent cf same,acknowledge that all site,andior project specific,PHSIEHD 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 ani Standards and State andor <br /> Federal Laws <br /> A"oLICANT'S SIGNATURE: Date 1 I <br /> ft—gram Records to be TRANSFERED: '$25.00= Amount Paid Date ! ! <br /> Water System to be TRANSFERED Amount Paid Date 1 ! <br /> Payment Type Check Number Received by <br /> RENS: Date ! I Account out: Date I ! <br /> COMMENTS' <br />