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Date n7i :3126/2014 3:25:10PK SAN JOf� ;IN CQUNTY ENVMONMENTAL HEAD vDEPARTMENT ;Rep.1#5;0221 v v et <br /> Run by Facility Information as of 3/26/2014 <br /> Record Selection Criteria: Facility ID FA0012734 <br /> Make changes/corrections 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 10,414,483 <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 5918 Stoneridge Mall Rd. <br /> Pleasanton, CA 94588 <br /> Care of Safeway, Inc <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 003- BESTOLARIDES Fax <br /> APN 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 <br /> Account ID AR0021257 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name Safeway Store 1769 (Circle one) <br /> Account Balance as of 3/26/2014: $-37.80 <br /> (Circle One) <br /> Transfer to Adive/Inaclve <br /> Progra"Element and Deaonpbon Rewind ID Employee ID and Name Status New Owneo Delete <br /> 1619-RETAIL MKT>1000 So FT(=/>2 DEPTS) PRO516675 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> 1920-HMBP-Common Materials PRO537805 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO538350 EE0004636-GARRETT BACKUS Active Y N A I D <br /> BILLING and!COMPLANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ander project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to me pony identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and State ander <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 <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date / / <br /> COMMENTS: <br />