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Date run 7/19/2013 10:58:36AI SAN JO*IN COUNTY ENVMONMENTAL HEAL.DEPARTMENT Report 175021 <br /> Run by Pagel <br /> Facility Information as of 7/19/2013 <br /> Record Selection Criteria: Facility ID FA0021728 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0001336 New Owner ID <br /> Owner Name COSTCO WHOLESALE CORPORATION <br /> Owner DBA COSTCO <br /> Owner Address 999 LAKE DR <br /> ISSAQUAH, WA 98027 <br /> Home Phone 425-313-8156 <br /> Work/Business Phone 425-313-2970 <br /> Mailing Address PO BOX 35005 <br /> SEATTLE, WA 981243405 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0021728 <br /> Facility Name COSTCO <br /> Location 3250 W GRANTLINE RD <br /> TRACY, CA 95304 <br /> Phone <br /> Mailing Address 999 LAKE DR <br /> ISSAQUAH, WA 98027 <br /> Care of <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMail <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0039461 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name KLEINFELDER (Circle One) <br /> Account Balance as of 7/19/2013: $-250.00 <br /> (Circe One) <br /> Transfer to Activelmeove <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0537704 EE0001699-JOHNNY YOAKUM Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of seme,acknowledge that all site,andtor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form I also certify that all operations wu be performed in accordance with all applicable Ordinance Codas anter standards and State and'or <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: Date /_/_ Account out: Date <br /> COMMENTS: <br />