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Daterun /2973 09 4:06:54PM SAN JOIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run byPagel <br /> Facility Information as of 3/9/2009 <br /> Record Selection Criteria: Facility ID FA0000380 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0000311 New Owner ID <br /> Owner Name KMART <br /> Owner DBA <br /> Owner Address 5400 AUBURN BLVD <br /> SACRAMENTO, CA 95841 <br /> Home Phone Not Specified <br /> Work/Business Phone 248-643-1000 <br /> Mailing Address 3333 BEVERLY RD <br /> HOFFMAN ESTATES, IL 60179 <br /> Care of DEPT768 TAX B2-113A <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000380 <br /> Facility Name KMART#7486 <br /> Location 520 S CHEROKEE LN <br /> LODI, CA 95240 <br /> Phone 209-333-0220 <br /> Mailing Address 3333 BEVERLY ROAD <br /> HOFFMAN ESTATES, IL 60179 <br /> Care of D 768 TAX, B2-113A <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 04745017 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name EATERY EXPRESS-KMART <br /> Title <br /> Day Phone 209-333-0220 <br /> Night Phone 209-333-0220 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000379 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name KMART#7486 (Circle One) <br /> Account Balance as of 3/9/2009: $0.00 <br /> (Circle One) <br /> Transferto AcdveMactve <br /> Program/Element and Description ID Employee ID and Name Status New Omen Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO161841 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPRO512119 EE0000000-HAZ MAT SJC OES Inactive Y N A 1 D <br /> 2244-PACT TRANSFER RECORD-DES PR0519900 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0509831 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO523650 EE5555555-Garrett Alias-Backus Inactive 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,PHS/EHD hourly charges associated with this <br /> facility or activity 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 Ordinate Codes and/or Standards and <br /> State andfor Federal Laws. <br /> P'e H--&v :is.,S'r Tcr 'r � lT Ul 101 S'z BS <br /> APPLICANT'S SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: "$372.00= Amount Paid Date <br /> Payment Type Check Number Recei ,,Q <br /> REHS: Date 3 /�/ Account out: Date / l / <br /> COMMENTS: �TTT <br /> \\eh-env\envision\reports\5021.rpt <br />