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Date.mn 9,a8/2008,11:53:12AIReport#5021 <br /> SAN JOAIN COUNTY ENVIRONMENTAL HEALEPARTMENT <br /> Run by 1273 Pagel <br /> Faeility Information as of 9/18/20 <br /> Record Selection Criteria: Facility ID FA0010425 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008425 Case Number: H08067 New Owner ID <br /> Owner Name SMART& FINAL STORE CORP <br /> Owner DBA SMART& FINAL FOODSERVICE <br /> Owner Address PO BOX 512377 <br /> LOS ANGELES, CA 900510377 <br /> Home Phone Not Specified <br /> Work/Business Phone 323-869-7901 <br /> Mailing Address 4343 E FREMONT ST <br /> STOCKTON, CA 95215 <br /> Care of <br /> FACILITY FILE INFORMATION Site Mitigation Facility <br /> Facility ID FA0010425 <br /> Facility Name SMART& FINAL FOOD SERVIC <br /> Location 4343 E FREMONT ST <br /> STOCKTON, CA 95215 <br /> Phone 209-948-1814 <br /> Mailing Address 4343 E FREMONT ST <br /> STOCKTON, CA 95215 <br /> Care of <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 14328039 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 AR0017425 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name SMART& FINAL STORE CORP (Circle One) <br /> Account Balance as of 9/18/2008: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inaotve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOIPR0512713 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2244-PACT TRANSFER RECORD-DES PR0520340 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2381 -UST FACILITY(BEFORE 1/84)-obsolete PR0232095 EE0000451 -STEVE SASSON Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARPR0510425 EE0000000-HAZ MAT SJC OES Inactive 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 speck,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party idenlifedps the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes andlor Standards and <br /> State and/or Federal Laws. L7�YA•[`p/•�/Yj <br /> 2aad 'f F��6as <br /> APPLICANT'S SIGNATURE: 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 Receiv <br /> REHS: Date_/ / Account out: <br /> COMMENTS: <br /> \\phs-ehsql-nt\apps\envisions\reports\5021.rpt <br />