SITE INFORMATION AND CORRESPONDENCE_FILE 1

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Run by : SANDY e?f Joaquin County PHS/EHD ^ Report #5021 FACILI.LTY INFORMATION as of 11/09/95 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Make changes/corrections in RED pen or pencil: OWNER FILE INFORMATION INFORMATION CHANGE (date): OWNERSHIP CHANGE (date): OWNER 1D: 005602 New Owner ID: 00 n ) Owner Name: e Q� �/ I Qx� n�lk oI/� Owner DBA: owner Address: 2130 PROFESSIONAL DR, STE 100 /D Dod ROSEVILLE, CA 95661 p ¢� (� A Home Phone: 916- 774-2942 0 Work/Business Phone: 916-774-3004 Mailing Address: 2130 PROFESSIONAL DR, STE 100 Care of: ROSEVILLE, CA 95661 FACILITY FILE INFORMATION FACILITY ID: 006840 In • /X/ Facility Name: -- +l OIL CC) 3 77 T05C0 SLLA-f' TM aV � Location: 7647 PACIFIC AVE STOCKTON 95207 Phone: 209-952-4515 Mailing Address: 2130 PROFESSIONAL DR, STE 100 care of: TOSCO CORP ROSEVI-LLE, CA 95661 Location Code: 01 APN: BOS District: SIC Code: ACCOUNTS RECEIVABLE FILE INFORMATION 11 • ACCOUNT ID: 0009519 New Account ID: 000 Mail Invoices to: Owner Mail Invoices to: Owner / Facility / count 49count Name: TOSCO NORTHWEST CO (Circle one) Account Balance as of 11/09/95 : $0 . 00 (circle o Record UST(s) Transfer to Activate Inactivate P/E Description 10 Employee Status Linked new owner? Delet - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 2950 ENVIRON ASSESS PR505534 0684 INFURNA AALNVE Y N A 0 D - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -'i 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 BILLING PARTY on this form. I also certify that all operations will be performed in accordance with all applicable SAN JOAQUIN COUNTY Ordinance Codes and/or Standards and State and/or Federal Laws. APPLICANT'S SIGNATURE: Date - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - PR Records to be TRANSFERED: x $20.00 = Amount Paid Date—/—/ Water System to be TRANSFERED: x $150.00 = Amount Paid Date—/—/ Payment Type Check # Recvd by REHS or COUNTER SUPV Date/ e/ ACCT out Date/q/ UNIT/File:_ZJ Run by : SANDY San Joaquin Count PHS/EHD Report #5021 FACILITY INFORMATION as of 11/09/95 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Make changes/corrections in RED pen or pencil: