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Date run 6/19/2014 3:44:39PA SAN JOA40N COUNTY ENVIRONMENTAL HEALTOPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/19/2014 <br /> Record Selection Criteria: Facility ID FA0022540 <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 OW0020087 New Owner ID <br /> Owner Name O'Reilly Auto Enterprises, L.L.C. <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 417-862-3333 <br /> Mailing Address 702 E. Bethany Home Road <br /> Phoenix, AZ 85014 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0022540 10586497 <br /> Facility Name O'Reilly Auto Parts#4719 <br /> Location 15079 S Harlan Rd <br /> Lathrop, CA 95330 <br /> Phone 209-234-1895 x <br /> Mailing Address 3E Company, Reg. Dept/O'Reilly Auto Parts, 3 <br /> Carlsbad, CA 92010 <br /> Care of O'Reilly Auto Enterprises, L.L.C. <br /> Location Code Alt Phone <br /> BOIS District Fax - <br /> APN 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 AR0041232 New Account ID: <br /> Maillnvoicesto Facility Mail invoices to: Owner / Facility / Account <br /> Account Name O'Reilly Auto Parts#4719 (Circle One) <br /> Account Balance as of 8/19/2014: $0.00 <br /> (Circle One) <br /> Transfer to ActiveMactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0539435 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0539434 EE0002646-THUY TRAN Active 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,PHS'EHD 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 andror Standards and State andlor <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 RecelVfby <br /> REHS: Date / / 1 Account out: _ XfADate / /1,— <br /> COMMENTS: <br /> �1Lt, '7 C1♦CMS Eos tont <br /> '� 114v�a5�-�85 <br /> �,Q r� FA<-, t,t %j V,R r L4 5 <br />