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Date run 8/5/2015 8:59:38AM SAIOAQUIN COUNTY ENVIRONMENTALHTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/5/2015 <br /> Record Selection Criteria: FacilityID FA0000838 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 8 SSN/Fed Tax ID <br /> Owner ID OW0009310 New Owner ID <br /> Owner Name Safeway, Inc. <br /> Owner DBA SAFEWAY INC <br /> OwnerAddress 5918 STONERIDGE MALL RD <br /> PLEASANTON, CA 945883229 <br /> Home Phone 925-469-7164 <br /> Work/Business Phone 925467-3000 <br /> Mailing Address 5918 Stoneridge Mall Rd. <br /> Pleasanton, CA 94588 <br /> Care of MS#6516 TAX, NASC <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0000838 10156541 <br /> Facility Name Safeway 3124 <br /> Location 1187 S MAIN ST <br /> Manteca, CA 95336 <br /> Phone 925-467-3000 x <br /> Mailing Address PO Box 29096, MS 6516 <br /> Phoenix,AZ 85038 <br /> care of Safeway, Inc. <br /> Location Code 04- MANTECA Alt Phone <br /> BOS District 005 - ELLIOTT, BOB 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 AR0000836 NewAccount ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Kahty Hjelm (Circle One) <br /> Account Balance as of 8/5/2015: $0.00 <br /> (Circle One) <br /> Transfer to Active�lnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owned Delete <br /> 1921 -HMBP-Regular-Primary Location PRO538962 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PR0538961 EE0005642-MICHELLE HENRY Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project spec,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 will be performed in accordance with all applicable Ordinance Codes ander Standards and Slate andlor <br /> Federal Lewis <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: AmountPaid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: Date_/ / Account out: Date <br /> COMMENTS: Invoice 11: <br />