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Date Ian 2/21/2012 11:52:45AI SAN JUIN COUNT*ENVIRONMENTAL HE DEPARTMENT Paget Report#5021 <br /> Run by <br /> Facility Information as of 2/21/2 <br /> Record Selection Criteria: Facility ID FA0003815 <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 I OW0002829 New Owner ID <br /> Owner Name TESORO REFINING & MARKETING CO <br /> Owner DBA <br /> Owner Address 19100 RIDGEWOOD PKWY <br /> SAN ANTONIO, TX 78259 <br /> Home Phone 253-896-8700 <br /> Work/Business Phone Net SpCClfled— <br /> Mailing Address 19100 RIDGEWOOD PKWY MS TX1-022 <br /> SAN ANTONIO, TX 78259 <br /> Care of TRAG'f -eWAN fqa ip Arc A <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0003815 <br /> Facility Name USA GAS STATION#68154* <br /> Location 2500 W LODI AVE S <br /> LODI, CA 95240 <br /> Phone 209-366-0703 <br /> Mailing Address 19100 RIDGEWOOD PKWY MS TX1-022 <br /> SAN ANTONIO, TX 78259 <br /> Care of TRAICyr- N L+17a _ <br /> Location Code 02 - LODI Alt Phone Z( I (p <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 02740006 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name JOCK STREIDL <br /> Title <br /> Day Phone 253-896-8734 <br /> Night Phone 253-896-8734 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0003402 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name USA GAS STATION#68154* (Circle One) <br /> Account Balance as of 2/21/2012: $1,517.00 <br /> (Circle One) <br /> Transfer to Active/Inadve <br /> Program,Element and Description Recent ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONSNR PRO516543 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO511902 EEOOOOo00-HAZ MAT SJC DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PRO519773 EE0000000-HAZ MAT SJC DES Active Y N A I D <br /> 2301 -UST STATE SURCHARGE FEE PR0508263 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> 2361 -UST FACILITY PR0231356 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARIPRO506801 EE0004636-GARRETT BACKUS Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPR0532641 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project spec,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the parry identified as the OWNER on this form. I also certify mal all operations will be performed in accordance with all applicable Ominace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Date I / <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 -7 <br /> REHS: Date / / Account out: �^ Date ! / (i <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />