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#5021 <br /> Date run 7/18/2013 1:45:58Ph SAN JO N COUNTY ENVIRONMENTAL HEAL EPARTMENT Report egal <br /> Run by Facility Information as of 7/18/2013 <br /> Record Selection Criteria: Facility ID FA0014131 <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 �� Site Mitigation Facility <br /> Facility ID/CERS ID FA 4131 v <br /> Facility Name STCO WH LESALE#658 <br /> Location 3250 W GRANT LINE RD <br /> TRACY, CA 95377 <br /> Phone 209-830-5343 <br /> Mailing Address 3250 W GRANT LINE RD <br /> TRACY, CA 95377 <br /> Care of CANO, PAUL <br /> Location Code <br /> 03-TRACY Alt Phone <br /> SOS District 005 - ELLIOTT, BOB Fax <br /> APN 23860006 Email: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name CANO, PAUL <br /> Title ADMINISTRATION OFFICER <br /> Day Phone 209-830-5343 <br /> Night Phone 209-836-1096 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> New Account ID: <br /> Account ID AR0023909 <br /> Mail Invoices to: Owner I Facility / Account <br /> Maillnvoicesto Owner (Circle One) <br /> Account Name COSTCO WHOLESALE CORPORATION <br /> Account Balance as of 7/18/2013: $0.00 (Circle One) <br /> Transfer to Aclivellnactve <br /> ProgrartJElemenlentl Description Record ID Employee ID and Name <br /> Status New Owner? Delete <br /> > PR0518777 EE0001420-MELISSA NISSIM Active Y N A I D <br /> 1619-RETAIL MKT>100 SQ FT(_/ 2 DEPTS) <br /> 4740-WASTE TIRE SITE-EXEMPT <br /> PR0522396 EE0002622-BENJAMIN ESCOTTO Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,the undersigned oymer,operator oragent tisame.lacknowiedge <br /> rm.the.allsite,andor project lica ile OrdinanHSIEHD ce <br /> charges associated with this facility <br /> or activity will be bitted to the party identified as the OWNER on this form also ostlify that all operations will be pedormetl in accortlance with all applicable Ordinance Codes andor Standards and State anb'or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Amount Paid Date <br /> Water System to be TRANSFERED: Received by <br /> Payment Type Check Number Date <br /> REHS: Date_/_/_ Account out: <br /> COMMENTS: <br />