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Date run 11/14/2014 11:35:21! SAN JO IN COUNTY ENVIRONMENTAL HEAIODEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 11/14/2014 <br /> Record Selection Criteria: Facility IQ FA0022662 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: I SSN I Fed Tax ID <br /> Owner ID OW0020311 New Owner ID <br /> Owner Name Walgreen Co. <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 847-914-2264 <br /> Mailing Address 200 Wilmot Road <br /> Deerfield, IL 60015 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0022662 10600501 <br /> Facility Name Walgreens#13984 <br /> Location 1528 E FREMONT ST <br /> Stockton, CA 95205 <br /> Phone 209-467-7861 x <br /> Mailing Address 3E Company, Reg.Dept. 1 Walgreen Co., 3207 <br /> Carlsbad, CA 92010 <br /> Care of Walgreen Co. <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 AR0041488 New Account ID: <br /> Mail Invoices to Account'/ Mail Invoices to: Owner f Facility 1 Account <br /> Account Name 3E Company/Regulatory Departmen green-i (Circle One) <br /> Account Balance as of 1111412014: $0.00 <br /> (Circle Cine) <br /> Transfer to Activellnactve <br /> ProgramlElemert and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONSIYR PR0539612 EE0009488-JEFFREY WONG Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHS/EiD 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 andlor Standards and State andlor <br /> Federal Laws_ <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date ! / <br /> Payment Type Check Number Recei d <br /> REH& vvtJ Date 11 _ Account out: Date l �1 <br /> COMMENTS: <br /> G1-e*1C-o N6�"j VIA <br />