SEC FORM
4
SEC Form 4
| FORM 4 |
UNITED STATES SECURITIES AND EXCHANGE COMMISSION
Washington, D.C. 20549
STATEMENT OF CHANGES IN BENEFICIAL OWNERSHIP
Filed pursuant to Section 16(a) of the Securities Exchange Act of 1934
or Section 30(h) of the Investment Company Act of 1940
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| OMB APPROVAL |
| OMB Number: |
3235-0287 |
| Estimated average burden |
| hours per response: |
0.5 |
|
|
 |
Check this box if no longer subject to Section 16. Form 4 or Form 5 obligations may continue.
See
Instruction 1(b). |
1. Name and Address of Reporting Person*
(Street)
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2. Issuer Name and Ticker or Trading Symbol
PREMCOR INC
[ PCO ]
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5. Relationship of Reporting Person(s) to Issuer
(Check all applicable)
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Director |
X |
10% Owner |
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Officer (give title below) |
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Other (specify below) |
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3. Date of Earliest Transaction
(Month/Day/Year)
05/27/2005
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4. If Amendment, Date of Original Filed
(Month/Day/Year)
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6. Individual or Joint/Group Filing (Check Applicable Line)
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Form filed by One Reporting Person |
| X |
Form filed by More than One Reporting Person |
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| Table I - Non-Derivative Securities Acquired, Disposed of, or Beneficially Owned |
|---|
| 1. Title of Security (Instr.
3)
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2. Transaction Date
(Month/Day/Year) |
2A. Deemed Execution Date, if any
(Month/Day/Year) |
3. Transaction Code (Instr.
8)
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4. Securities Acquired (A) or Disposed Of (D) (Instr.
3, 4 and 5)
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5.
Amount of Securities Beneficially Owned Following Reported Transaction(s) (Instr.
3 and 4)
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6. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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7. Nature of Indirect Beneficial Ownership (Instr.
4)
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| Code |
V |
Amount |
(A) or (D) |
Price |
| Common Stock |
05/27/2005 |
|
G |
|
1,908,209 |
D |
$0
|
0 |
D |
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| Common Stock |
05/27/2005 |
|
G |
|
1,908,209 |
A |
$0
|
9,034,646 |
I |
by subsidiary
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Table II - Derivative Securities Acquired, Disposed of, or Beneficially Owned
(e.g., puts, calls, warrants, options, convertible securities)
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|---|
| 1. Title of Derivative Security (Instr.
3)
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2. Conversion or Exercise Price of Derivative Security
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3. Transaction Date
(Month/Day/Year) |
3A. Deemed Execution Date, if any
(Month/Day/Year) |
4. Transaction Code (Instr.
8)
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5.
Number of Derivative Securities Acquired (A) or Disposed of (D) (Instr.
3, 4 and 5)
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6. Date Exercisable and Expiration Date
(Month/Day/Year) |
7. Title and Amount of Securities Underlying Derivative Security (Instr.
3 and 4)
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8. Price of Derivative Security (Instr.
5)
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9.
Number of derivative Securities Beneficially Owned Following Reported Transaction(s) (Instr.
4)
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10. Ownership Form: Direct (D) or Indirect (I) (Instr.
4)
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11. Nature of Indirect Beneficial Ownership (Instr.
4)
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| Code |
V |
(A) |
(D) |
Date Exercisable |
Expiration Date |
Title |
Amount or Number of Shares |
1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
| 110 WEST 7TH STREET |
| P.O. BOX 200 |
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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1. Name and Address of Reporting Person*
(Street)
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| Explanation of Responses: |
|
|
/s/ J. R. HAVERT, Vice President and Treasurer of Occidental Petroleum Corporation |
05/31/2005 |
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** Signature of Reporting Person |
Date |
| Reminder: Report on a separate line for each class of securities beneficially owned directly or indirectly. |
| * If the form is filed by more than one reporting person,
see
Instruction
4
(b)(v). |
| ** Intentional misstatements or omissions of facts constitute Federal Criminal Violations
See
18 U.S.C. 1001 and 15 U.S.C. 78ff(a). |
| Note: File three copies of this Form, one of which must be manually signed. If space is insufficient,
see
Instruction 6 for procedure. |
| Persons who respond to the collection of information contained in this form are not required to respond unless the form displays a currently valid OMB Number. |
JOINT FILER INFORMATION
Name: Occidental C.O.B. Partners
Address: 110 West 7th Street
P.O. Box 300
Tulsa, Oklahoma 74102
Designated Filer: Occidental Petroleum Corporation
Issuer & Ticker Symbol: Premcor Inc. (PCO)
Date of Event Requiring Statement: 05/27/2005
Signature: OCCIDENTAL C.O.B. PARTNERS
by OXY USA Inc., its managing partner
By: /s/ J. R. HAVERT
------------------------------------
J. R. Havert
Vice President and Treasurer
Page 3 of 7
JOINT FILER INFORMATION
Name: Placid Oil Company
Address: 10889 Wilshire Boulevard
Los Angeles, California 90024
Designated Filer: Occidental Petroleum Corporation
Issuer & Ticker Symbol: Premcor Inc. (PCO)
Date of Event Requiring Statement: 05/27/2005
Signature: PLACID OIL COMPANY
By: /s/ J. R. HAVERT
------------------------------------
J. R. Havert
Vice President and Treasurer
Page 4 of 7
JOINT FILER INFORMATION
Name: OXY USA Inc.
Address: 5 Greenway Plaza
Houston, Texas 77046
Designated Filer: Occidental Petroleum Corporation
Issuer & Ticker Symbol: Premcor Inc. (PCO)
Date of Event Requiring Statement: 05/27/2005
Signature: OXY USA INC.
By: /s/ J. R. HAVERT
------------------------------------
J. R. Havert
Vice President and Treasurer
Page 5 of 7
JOINT FILER INFORMATION
Name: Occidental Oil and Gas Holding
Corporation
Address: 10889 Wilshire Boulevard
Los Angeles, California 90024
Designated Filer: Occidental Petroleum Corporation
Issuer & Ticker Symbol: Premcor Inc. (PCO)
Date of Event Requiring Statement: 05/27/2005
Signature: OCCIDENTAL OIL AND GAS HOLDING
CORPORATION
By: /s/ J. R. HAVERT
------------------------------------
J. R. Havert
Vice President and Treasurer
Page 6 of 7
JOINT FILER INFORMATION
Name: Occidental Petroleum Investment Co.
Address: 10889 Wilshire Boulevard
Los Angeles, California 90024
Designated Filer: Occidental Petroleum Corporation
Issuer & Ticker Symbol: Premcor Inc. (PCO)
Date of Event Requiring Statement: 05/27/2005
Signature: OCCIDENTAL PETROLEUM
INVESTMENT CO.
By: /s/ J. R. HAVERT
------------------------------------
J. R. Havert
Vice President and Treasurer
Page 7 of 7
