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Date run 1/4/2016 9:53:35AM SAN JOA&NCOUNTY ENWIRONMENTALHEAL*EPARTMENT Report#5021 <br /> Run byPaget <br /> Facility Information as of 1/4/2016 <br /> Record Selection Criteria: Facility ID FA0012734 <br /> Make changes/correcitions in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID <br /> Owner ID OW0009849 New Owner ID <br /> Owner Name Safeway, Inc. <br /> owner DBA SAFEWAY STORE#1769 <br /> Owner Address 5918 STONERIDGE MALL RD <br /> PLEASANTON, CA 945883229 <br /> Home Phone 925-467-3845 <br /> Work/Business Phone 925-467-3000 <br /> Mailing Address 5918 Stoneridge Mall Rd. <br /> Pleasanton, CA 94588 <br /> Care of ROBERT DAWES <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0012734 10414483 <br /> Facility Name Safeway Store 1769 <br /> Location 2808 COUNTRY CLUB BLVD <br /> Stockton, CA 95204 <br /> Phone 925-467-3000 x <br /> Mailing Address PO Box 29096, MS 6516 <br /> Phoenix,AZ 85038 <br /> care of Safeway, Inc. <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 003 - BESTOLARIDES, STEVE Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name MS#6516 TAX NASC <br /> Title <br /> Day Phone 209-461-5555 <br /> Night Phone 925-467-3845 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0021257 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name KahtyHjelm (CirdeOne) <br /> Account Balance as of 1/4/2016: $0.00 (Circle One) <br /> Transfer to ActiveAnactve <br /> Program/Element and Description <br /> Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO537805 EE0000006-HAZA SAEED Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO538350 EE0001421 -STACY RIVERA 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 specific,PHSIEHD hourly charges associated with this facility or <br /> 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. <br /> APPLICANT'S SIGNATURE: Date <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 <br /> EHD Staff: Date_/ /_ Account out: Date <br /> COMMENTS: Invoice#: <br />