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FSelecti.1n <br /> 52:18PM SAN 1QUIN COUNTY PUBLIC HEALTH SER 7S Report #: 0002 <br /> _ <br /> Facility Information as of 5/16/01 Page #: 1 <br /> Facility ID FA0012652 <br /> Record ID <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE (date) <br /> OWNERSHIP CHANGE (date) <br /> OWNER FILE INFORMATION <br /> Owner ID: OW0009849 New Owner ID <br /> Owner Name: DAWES, ROBERT <br /> Owner DBA; SAFEWAY STORE#1769 <br /> Owner Address: 5819 STONERIDGE MALL RD <br /> PLEASANTON, CA 94588-3229 <br /> Home Phone; 925-467-3845 <br /> Work/Bussness Phone: Not Specified <br /> Mailing Address: 5819 STONERIDGE MALL RD <br /> PLEASANTON, CA 94588-3229 <br /> Care of: ROBERT DAWES <br /> FACILITY FILE INFORMATION <br /> Facility ID: FA0012652 <br /> Facility Name: SAF EWAY STORE#1769 <br /> Location: 2782 COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204 <br /> Phone: 925-467-3845 <br /> Mailing Address: 2782 COUNTRY CLUB BLVD <br /> STOCKTON, CA 95204- <br /> Care of• <br /> Location Code: 01 - STOCKTON APN: <br /> BOS District: 001 -GUTIERREZ, STEVE SIC Code; <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID: AR0020947 New Account ID:: <br /> Mail Invoices to: Account _ Mail Invoices to: Owner!Facility/Account ' <br /> Account Name; GEOT S ING !t (Circle One) C' . <br /> Account Balance as of 5/16/6: $-52.20 -- -- LL <br /> (Circle One) <br /> UST(s) Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Stat s Linked New Owner? Delete <br /> 2950-ENVIRON ASSESS PRO516515 EE0000684-INFURNA 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, <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on this form. I also certify that all <br /> operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$0.00= Amount Paid Date <br /> Water System to be TRANSFF4ED: '$150.00= Amount Paid Date <br /> Payment Type � t, / Check Number Receipt Number Received by <br /> REHS: — Date / f t l Account out: _ 1 / Date ' l <br /> 1.0.0.89.00 <br />