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Date run 7/30/2015 11:26:43AD SA*AQUIN COUNTY ENVIRONMENTAL TH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/30/2015 <br /> Record Selection Criteria: Facility ID FA0002890 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 14 SSN/Fed Tax ID : <br /> Owner ID OW0000478 New Owner ID <br /> Owner Name QUIK STOP MARKETS INC <br /> Owner DBA <br /> OwnerAddress 4567 ENTERPRISE ST <br /> FREMONT, CA 94538 <br /> Home Phone Not Specified <br /> Work/Business Phone 510-657-8500 <br /> Mailing Address 4567 ENTERPRISE ST <br /> FREMONT, CA 94538-7605 <br /> Care of QUIK STOP MARKETS INC <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID/CERS ID FA0002890 10181013 <br /> Facility Name QUIK STOP MARKET#2120* <br /> Location 9321 N THORNTON RD <br /> STOCKTON, CA 95209 <br /> Phone 209-478-7149 x <br /> Mailing Address 4567 ENTERPRISE ST <br /> FREMONT, CA 94538-7605 <br /> Care of NACHHATAR SIDHU & RUSE VENDER KAU[ <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 003-BESTOLARIDES, STEVE Fax <br /> APN 080-180-05 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name MRSIDHU <br /> Title MANAGER <br /> Day Phone 209-478-7149 <br /> Night Phone 209-825-5733 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002451 New Account ID: <br /> Mail Invoices to: Owner / Facility / AccountMail Invoices to Account <br /> ci ae one) <br /> Account Name QUIK STOP MARKET#2120* <br /> Account Balance as of 7/30/2015: $0.00 (Circle One) <br /> Transfer to ActiveAnactve <br /> Program/Element and Description <br /> Record ID Employee ID and Name Status New Owner/ Delete <br /> 1617-RETAIL MARKET>1000 SQ FT W/FOOD PREP PRO160306 EE0001084-STEPHANIE RAMIREZ Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PRO519618 EE0000006-HAZA SAEED Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PRO518567 EE0000005-FATINAH ZAREEF Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511708 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2361 -UST FACILITY PR0231261 EE0000005-FATINAH ZAREEF Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO507321 EE0000418-MICHAEL KITH Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO534475 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specTic,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the parry identified as the OWNER on this torte. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes anNor Standards and State andfor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: Date_/_/_ Account out: Date <br /> COMMENTS: Invoice 1f: <br />