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Date run 12/23/2014 3:26:05P SAN JOTIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by <br /> ` Facility Information as of 12/23/2014 pool* <br /> Record Selection Criteria: Facility ID FA0012386 <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: 4 SSN/Fed Tax ID : <br /> Owner ID OW0007783 New Owner ID <br /> Owner Name BRANNON, J/CUMBERLEGE, C <br /> Owner DBA BRANNON TIRE CORP <br /> Owner Address 3730 N WILSON WAY <br /> STOCKTON, CA 95205 <br /> Home Phone 209466-1881 <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 1988 <br /> STOCKTON, CA 95201 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0012386 10184211 <br /> Facility Name BRANNON TIRE <br /> Location 4905 CLAREMONT <br /> STOCKTON, CA 95207 <br /> Phone 209-477-9000 <br /> Mailing Address PO BOX 1988 <br /> STOCKTON, CA 95201 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 10223010 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0020240 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name BRANNON TIRE (Circle One) <br /> Account Balance as of 12/23/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name status New OwnsO Delete <br /> 1921 -HMBP-Regular-Primary Location PRO520924 EE0000006-HAZA SAEED Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0515933 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2227-GEN 5<25 TONS PERMIT PRO516229 EE0000005-FATINAH ZAREEF Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO515934 EE0009999-SITE UNASSIGNED Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO522554 EE0004045-TED TASIOPOULOS Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532934 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of some,acknowledge that all site,andor project specific,PHSIEHO hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form, l also certify that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and State ands <br /> Federal 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 Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />