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Date run 1/13/2014 12:32:37PI SAN J(>� IN COUNTY ENVIRONMENTAL HEA DEPReport 715021 <br /> DEPARTMENT Paget <br /> Run by Facility Information as of 1/13/2014 <br /> Record Selection Criteria: Fatality ID FA0012734 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSNI 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 lD/CERS ID FA0012734 10414483 <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 /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name Safeway Store 1769 (Circle D.) <br /> Account Balance as of 1/13/2014: $404.00 <br /> (circle One) <br /> Transfer to ActiveMacb,e <br /> ProgranVElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1619-RETAIL MKT>1000 SQ FT(=/>2 DEPTS) PRO516675 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> 1 MBP-Common Materials PR0537805 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> 2220 M P- GEN<5 TONS/YR PR0538350 EE0004636-GARRETT BACKUS Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andor project spec,PHSrEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form 1 also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor standards and state andor <br /> 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 Received by <br /> REHS: k-r\/ N!�q� Date�_/�_/ I Account out: , Date / / ly <br /> COMMENTS: <br /> A"o 0C' V <br />