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tate run + 3/29/2016 11:36:52AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 45021 Run by Pagel Facility Information as of 3/29/2016 Record Selection Criteria: Facility ID FA0003719 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0006297 Owner Name SAINI, SURINDER SINGH Owner DBA Owner Address 14836 HARBOR CT Facility Name LATHROP, CA 95303 Home Phone 209-992-1735 Work/Business Phone 209-992-1735 Mailing Address 14823 HARBOR CT Mailing Address LATHROP, CA 95303 Care of RAVINDER SINGH FACILITY FILE INFORMATION Facility ID / CERS ID FA0003719 10181343 Facility Name WEST LANE CHEVRON Location 4747 WEST LN (Circle One) STOCKTON, CA 95210 Phone 209-472-1639 x Mailing Address 4747 WEST LN Active/Inactve STOCKTON, CA 95210 Care of RAVINDER SINGH Location Code 01-STOCKTON Bos District 003 - BESTOLARIDES, STEVE APN 10437010 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name Ravinder Singh Title Store Manager Day Phone 209-472-1639 Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0003298 Mail Invoices to Account Account Name WEST LANE CHEVRON Account Balance as of 3/29/2016: $0.00 61 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN /Fed Tax ID: New Owner ID ' C i ti9 9 -'30 Alt Phone Fax EMail: OLU/lr'� �- New Acc Mail Invoices to: w r / acility / Account irc ) J 17 APPLICANT'S SIGNATURE: Date /-� Program Records to be TRANSFERED: * $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number _ Received by EHD Staff: Date / z / i (_ Account out: _� Date COMMENTS: Ir1V01Ce #: (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1921 - HMBP-Regular-Primary Location PRO520035 EE0000006 - HAZA SAEED Active N g I D 2220 - SM HW GEN <5 TONS/YR PR0514134 EE0000005 - FATINAH ZAREEF Active N I D 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512318 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2301 - UST STATE SURCHARGE FEE PRO508293 EE0000418 - MICHAEL KITH Inactive( N A I D 2361 - UST FACILITY PR0232482 EE0000005 -FATINAH ZAREEF Acti, Y N & I D 2399 - UNIFIED PROGRAM FAC STATE SURCHARGE F PR0507419 EE0000418 - MICHAEL KITH Inactive Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0531756 Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andlor project specific, PHS/EHD hourly charges associated with this 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 Ordinance Codes and/or Standards and Slate and/or Federal Laws. J 17 APPLICANT'S SIGNATURE: Date /-� Program Records to be TRANSFERED: * $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number _ Received by EHD Staff: Date / z / i (_ Account out: _� Date COMMENTS: Ir1V01Ce #: