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run <br /> Ruoby' 3/28/2012 4:40:56Ph SAN JUIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5o21 <br /> Facility Information as of 3/28/2 Pagel <br /> Record Selection Criteria: Facility ID FA0000380 <br /> Make changes/corrections in RED ink. �r2 <br /> INFORMATION CHANGE(date) C/ <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 3333 BEVERLY RD <br /> HOFFMAN ESTATES, IL 60179 <br /> Home Phone 847-286-0037 <br /> Work/Business Phone 847-286-7222 <br /> Mailing Address 3333 BEVERLY RD <br /> HOFFMAN ESTATES, IL 60179 <br /> Care of A p _, U TAA <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 _ w1 /,�yv T�.�`'t 1 <br /> Location Code 02-LODI Amine <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 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name KMART#7486 (Circle One) <br /> Account Balance as of 3/28/2012: $577.00 <br /> (Circle One) <br /> Pmgram/Element and Description Transfer to Active/Inactve <br /> Record ID I%'ee ID and Nama Status <br /> New OwneR Delete <br /> 1618-RETAIL MKT>2000 SO FT (PREPKGD/LTEPRO161841 EE0001084-STEPHANIE RAMIREZ Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PRO519900 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO529405 EE0005642-MICHELLE HENRY Active Y N A I D <br /> 2224-OBSOLETE HM BUSINESS PLAN PRO512119 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARIPRO509831 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0523650 EE5555555-Garrett Alias-Backus Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPRO531321 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,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 perfonned in accordance with all applicable On ince Codes and/or Standards and <br /> 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 I ed by <br /> REHS: Date_/ /_ Account out: Date _/ <br /> COMMENTS: <br /> \teh-envlenvisiontreportst.5021.rpt <br />