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Date run 8/19/2014 3:35:10Pk SAN JOA*COUNTY ENVIRONMENTAL HEALTOPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/19/2014 <br /> Record Selection Criteria: Facility ID FA0022539 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0020086 New Owner ID : <br /> Owner Name Costco Wholesale Corporation <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 425-313-8100 <br /> Mailing Address 999 Lake Drive <br /> Issaquah, WA 98027 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FAD022539 10584298 <br /> Facility Name Costco Depot#725 <br /> Location 25149 S. Schulte Rd. <br /> Tracy, CA 95377 <br /> Phone 209-221-8400 x <br /> Mailing Address Costco Wholesale Attn: Licensing, P.O. Box 3! <br /> Seattle, WA 98124-3405 <br /> Care of Costco Wholesale Corporation <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 AR0041231 New Account to: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name Costco Depot#725 (Circle One) <br /> Account Balance as of 8/19/2014: $0.00 <br /> (Circle One) <br /> Transfer to AcliveAnactve <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Reqular-Primary Location PR0539433 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0539432 EE0002646-THUY TRAN Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as me OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Faderal Laws. <br /> APPLICANTS 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 ,u Recei <br /> RENS: Date / /� Account out: Date / <br /> COMMENTS: <br /> c�I j�Q-LTLh F A(,L L,L'0j J-- 2. PIU(sN —KA"15 v t Ar Ch4-5 <br /> VC-c- Fay Ir" <br />