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Date run 3/10/2015 10:55:12AI SAN JO. IN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Repon#5021 <br /> Run by Pagel <br /> Facility Information as of 3/10/2015 <br /> Record Selection Criteria: Facility ID FA0003278 <br /> Make changeslcorrections 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 OW0002315 New Owner ID <br /> Owner Name Kmart Corporation <br /> Owner DBA <br /> Owner Address 3333 BEVERLY RD <br /> HOFFMAN ESTATES, IL 60179 <br /> Home Phone 124-846-3100 <br /> Work/Business Phone 847-286-0037 <br /> Mailing Address 3333 Beverly Road, 135-348A <br /> Hoffman Estates, IL 60179 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0003278 10140597 <br /> Facility Name Kmart#3174 <br /> Location 2180 E Mariposa Rd <br /> Stockton, CA 95205 <br /> Phone 209-948-8205 x <br /> Mailing Address 2180 E Mariposa Rd ' <br /> Stockton, CA 95205 <br /> Care of Kmart Corporation <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name WART CORP <br /> Title <br /> Day Phone 209-948-8205 <br /> Night Phone 209-948-8205 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002852 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Kmart#3174 (Circle One) <br /> Account Balance as of 3/10/2015: $0.00 <br /> (Circle One) <br /> Transferto Active/Inecive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1614-FOOD EST>1001 SQ FT W/O SEATING PRO161524 EE0008999-LEYNA HUYNH Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0520022 EE0000006-HAZA SAEED Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO531067 EE0005642-MICHELLE HENRY Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO512300 EEOOOOOOO-HAZ MAT SJC DES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0502273 EE0000008-LETITIA BRIGGS Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO510012 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO523647 EE0009000-HARPRIT MATTU Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO634064 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSIEHD hourly charges associated with this facility <br /> or activrty will 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 anNor Standards and State anNor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date_/ /_ <br /> Water System to be TRANSFERED: Amount Paid Date / I <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />