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Date run 6/7/2013 :23PM SAN JO IN COUNTY ENVIRONMENTAL HEA EPARTMENT Report#5021 <br /> Pagel <br /> Run by Facility Information as of 6/7/2013 <br /> Record Selection Criteria: Facility ID FA0012734 <br /> Make Changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner lD OW0009849 New Owner ID <br /> owner Name DAWES, ROBERT <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 623-869-6100 <br /> Mailing Address 5918 STONERIDGE MALL RD <br /> PLEASANTON, CA 945883229 <br /> Care of ROBERT DAWES <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0012734 10,414,483 <br /> Facility Name SAFEWAY#1769 <br /> Location 2808 COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204 <br /> Phone 209-461-5555 <br /> Mailing Address PO BOX 29096 <br /> PHOENIX, AZ 850389096 <br /> Care of MS#6516 TAX NASC <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 003- BESTOLARIDES Fax <br /> APN 12118043 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name ROBERT KENNEDY <br /> Title <br /> Day Phone 925-467-3000 <br /> Night Phone 209-461-5555 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION New Account ID: <br /> Account IO AR0021257 <br /> mail invoices to: Owner / Facility / Account <br /> Maillnvoicesto Facility (Circle One) <br /> Account Name SAFEWAY#1769 <br /> Account Balance as of 6/7/2013: $0.00 (circle one) <br /> Transfer to Activellnaclve <br /> PrograMElement and Description Record ID Employee ID and Name <br /> Status New Owner? Delete <br /> PR0516675 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> 1619-RETAIL MKT>1000 SOFT MEET DEPTS) PHS/EHD hour) charges associated with lhisfecilily <br /> BILLING end COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator a agent ti same,acknowledge that all site,endor projectapplicable <br /> specific, Y <br /> or activity will be billed to the party identified as the OWNER on this form lelso certify that all operations will be performed in accordance with all applicable Ordinance Cotlas endor Standards and Stele endor <br /> Federal Laws. <br /> Date <br /> APPLICANT'S SIGNATURE: <br /> Amount Paid Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Rece v y <br /> Payment Type Check Number <br /> REHS: —o Z _ Date / 3_/ t Account out: Date <br /> COMMENTS: OL r I I 0 <br />