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d Date run 9/13/2012 2:50:24PR SAN JO JIN COUNTY ENVIRONMENTAL HEA] DEPARTMENT Report#5021 Run by I Pagel Facility Information as of 9/13/2012 Record Selection Criteria: Facility ID FA0007491 OWNER FILE INFORMATION Owner ID OW0005013 Owner Name VALLEY PACIFIC PETROLEUM SERVICES Owner DBA Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Owner Address 166 A FRANK WEST CIR STOCKTON, CA 95206 Home Phone 209-948-9412 Work/Business Phone 209-993-8793 Mailing Address 166 FRANK WEST CIR STOCKTON, CA 95206 Care of VALLEY PACIFIC PETROLEUM SERV FACILITY FILE INFORMATION Facility ID FA0007491 Facility Name VALLEY PACIFIC FRESNO AVE CARDLOCK Location 1524 FRESNO AVE STOCKTON, CA 95206 Phone 209-948-9412 Mailing Address 166 FRANK WEST CIRCLE (Circle One) STOCKTON, CA 95206 Care of ELIASON, MIKE Location Code 01 -STOCKTON Bos District 001 - VILLAPUDUA APN 16337025 EMERGENCY NOTIFICATION CONTACT INFORMATION Alt Phone Fax EMail : Contact Name Title Day Phone Night Phone ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0011647 New Account ID: Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account Account Name VALLEY PACIFIC FRESNO AVE CARDLOCK (Circle One) Account Balance as of 9/13/2012: $25.00 I v1 (Circle One) n -I Transfer to Active/Inaclve rogranVElement and Description Record ID Employee ID and Name Status New Owner? nDelete ;PfIF!HM13P-Regullar-Primary Location PR0521056 EE-@fYM 0 - HAZ MAT SJC OES Inactive Y N A I D 2220 - SM HW GEN <5 TONS/YR PR0518517 EE0001421 -STACY RIVERA Active Y N A I D 2224 - HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0513176 EE0000000 - HAZ MAT SJC OES Inactive Y N A I D 2301 - UST STATE SURCHARGE FEE PR0516168 EE0002670 - MUNIAPPA NAIDU Inactive Y N A I D 2361 - UST FACILITY PR0506545 EE0001421 - STACY RIVERA Active Y N A I D 2399 - UNIFIED PROGRAM FAC STATE SURCHAR(PR0507670 EE0002670 - MUNIAPPA NAIDU Inactive Y N A I D ERSC - ELECTRONIC REPORTING STATE SURCRPR0533714 Active Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or 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 State and/or Federal Laws. 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 Receiv REHS: Al . Date Cl /_�/�2 Account out: Date COMMENTS: