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Daft <br /> "r^, BtalZOn 4:07:05PM SAN JOAQUIN COUNTY ENMONM ENTAL HEALTH DEPARTMENT - <br /> Run bRaportfSdpi <br /> Facility Information as of 8/2/2017 PaQel <br /> Reoad sb salon emmatc Faclity ID FA0010953 <br /> Maks chanaealcerrecuona In RED Ink, <br /> INFORMATION CKANGE(data) <br /> 0 I <br /> OWNER FILE INFORMATION Number of facilities fnr this owner: 1 OWNERSHIP CHANGE(date) <br /> SSN 1 Fed Tax ID <br /> Owner ID OW0008953 Case Number. H09961 Now Owner ID <br /> Owner Name TRI FORCE SOLUTIONS (r+ <br /> Owner DBA BIG 0 TIRES <br /> Owner Address 1129 W 11TH STE IV <br /> TRACY,CA 95376 37 <br /> Home Phone 209-836-2683 119 -am <br /> WorkBusiness Phone 209-836-9145 <br /> Mailing Address 1129 W 11TH ST 11W It S <br /> szet <br /> TRACY, CA 95376 RAN, 0 <br /> Cam of AMARJIT DALE <br /> FACILITY FILE INFORMATION <br /> Fedr7y ID I CERS ID FA001 M53 10183965 <br /> Facility Name BIG O TIRES c� <br /> Location 1129 W ELEVENTH ST 1(2-9 W fur SIM <br /> TRACY, CA 95376 A a p <br /> Phone 2836-2683 <br /> Mailing Address 1129 W 11TH ST f f Z R W S+4F <br /> TRACY, CA 95376 A <br /> Care of <br /> Location Code 03-TRACY Alt Phone <br /> 808 District 005-ELLIOTT, 8013 Fax <br /> APN 23229068 EMall: SQfV flit[ ft1P1 . C M <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name AMARJIT(SINGH)DALE T SIMA K96N OR dtlfYIfgj% <br /> Title WF <br /> Day Phone 209-836-2683 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017953 New Account ID: <br /> Mall invoices to Account Mall Invoices to: Owner I FadOty—A=unt <br /> Account Name BIG O TIRES (tee O1e) <br /> Account Balance as Of 81212017: $0.00 <br /> (CIrck one) <br /> men!ww Deaaripwn Record ID Emp"ID artd NameTrarister to Adiveltnadve <br /> Status Newowrnet? Deist* <br /> 2220-SM HW GEN-c6 TONSIYR PRO536969✓ EE0000016-BETTY HO ActiveY N A I D <br /> 4740-HAZ MAT BUSINESS PLAN AUTHORIZATIONPROS13241 EE0000000-HAZ MAT SJC OES Inactive N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO510953 EE0002822-BENJAMIN ESCOTTO Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE FEE PRO537009 Inactive Y N A 1 D <br /> OWNO and COWUAME ACKNOWMWEMENT:I,int urhmsigrgd awrnr,aParater or agentm aero,aclerow dpe that el fle,W*W proled apedGc,PMEHD hovrly charm asswww win it"fi <br /> dr adMty w14e"d to the puty JdeA%d as aro OWNER on this form. I also aNy that air opwallons will be peftmed in aeeordame with ei app rswe Ordlnanee Codes andrm Standards end Slate andlor <br /> FedenlLara. <br /> is A <br /> APPLICANT'S SIGNATURE: Date OOp. /11:21 <br /> Program Records to be TRANSFE D: '$25.00= Amount Paid Date ! 1 <br /> Water System to be TRANSFERED: Amount Paid Date ! I <br /> r r r <br /> Payment Type Check Number Received <br /> END staff Date ! Account out te ~ <br /> COMMENlTB: � :���I� <br /> I 2 2 Invotoe : <br /> nEAS <br /> "pd�' I 2 :� r f 1 c�r--� „, F�x.Q� MEALTK . <br /> DEPARTMENT <br />