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Date run 8/17/2009 3:57:25PN SAN J("1UIN COUNTY'ENVIRONMENTAL HEA' TH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/17/2L.—i <br /> Record Selection Criteria: Facility ID FA0019374 <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 OW0015881 New Owner ID <br /> Owner Name SANDFORD, SANDELMAN TR <br /> Owner DBA KIN PROPERTIES <br /> Owner Address 15350 SW SEQUOIA PKWY 300 <br /> PORTLAND, OR 97224 <br /> Home Phone 561-620-9200 <br /> Work/Business Phone Not Specified <br /> Mailing Address 185 NW SPANISH RIVER BLVD <br /> BOCA RATON, FL 33431 <br /> Care of CHERNEY, LEE <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0019374 <br /> Facility Name WALGREENS DRUG STORE <br /> Location 15 W HARDING WAY <br /> STOCKTON, CA 95204 <br /> Phone <br /> Mailing Address 185 NW SPANISH RIVER RD <br /> BOCA RATON, FL 33431 <br /> Care of CHERNEY, LEE <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 12707026 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0034423 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name BUREAU VERITAS (Circle One) <br /> Account Balance as of 8/17/2009: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0528915 EE0000684-MICHAEL 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,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: S C'_2 e► Q c� Q o S�a� C-��•n n fL `�� Date <br /> Program Records to be TRANSFERED: "$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: _tLZ3� Date S 0 <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />