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Date run 5/17/2018 1:45:49PIY SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 95021 <br /> Run by Pagel <br /> Facility Information as of 5/17/2018 <br /> Record Selection Criteria: Facility ID FA0004567 <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: 1 SSN/Fed Tax ID <br /> Owner ID OW0020845 New Owner ID <br /> Owner Name Tractor Supply Company <br /> Owner DBA <br /> Owner Address 5401 VIRGINIA WAY <br /> BRENTWOOD, TN 37027 <br /> Home Phone Not Specified <br /> Work/Business Phone 615-440-4600 <br /> Mailing Address 5401 Virginia Way <br /> Brentwood, TN 37027 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0004567 10181661 <br /> Facility Name Tractor Supply Company, #1857 <br /> Location 360 S Cherokee Ln <br /> Lodi, CA 95240 <br /> Phone 209-369-5528 x <br /> Mailing Address 5401 Virginia Way <br /> Brentwood, TN 37027 <br /> care of Tractor Supply Company <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN EMail <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name BRIAN SPEARS <br /> Title <br /> Day Phone 209-440-4600 <br /> Night Phone 615-440-4115 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004346 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Brian Spears (Circle One) <br /> Account Balance as of 5/17/2018: $0.00 <br /> (Circle One) <br /> Transferto ActiveJlnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO520360 EED008709-JAMIE LIMA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO535764 EE9999998-ONE VACANTI Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512347 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0510059 EEOOOOOOO-HAZ MAT SJC DES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0533774 Inactive 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 the 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 /> Federal Lewis <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Tye �M Check Number Received r <br /> EHD Staff: ��m� Date / 1-7 / 12 Account out: Date==11_z2_ <br /> COMMENTS: I <br /> ibUSI i Qs hw M b�4 c hgRr�-c�u.g <br /> Invoice#: <br /> 0111 pro ("W-. tempt- IMO . <br />