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Date run 9/17/2015 9:19:42AN SAN JC AN COUNTY ENVIRONMENTAL HEAj, DEPARTMENT Report#5021 <br />Run by - Pagel <br />Facility Information as of 9/17/2015 <br />Record Selection Criteria: Facility ID FA0022513 <br />OWNER FILE INFORMATION Number of facilities for this owner : 1 <br />Owner ID OW0020036 <br />Owner Name Tractor Supply Company <br />Owner DBA <br />Owner Address <br />Home Phone Not Specified <br />Work/Business Phone 615-440-4660 <br />Mailing Address 5401 Virginia Way <br />Brentwood, TN 37027 <br />Care of <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0022513 10453774 <br />Facility Name <br />Tractor Supply Store #1303 <br />Location <br />860 N JACK TONE RD <br />Ripon, CA 95366 <br />Phone <br />615-440-4600 x <br />Mailing Address <br />5401 Virginia Way <br />Brentwood, TN 37027 <br />Care of <br />Tractor Supply Company <br />Location Code <br />05 - RIPON <br />Bos District <br />005 - ELLIOTT, BOB <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />Title <br />Day Phone <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Account ID AR0041193 <br />Mail Invoices to Account Mail Invoices to: <br />Account Name Brian Spears <br />Account Balance as of 9/17/2015: $0.00 <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transferto Active/lnactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1920 - HMBP-Common Materials PR0539380 EE0002474 - MICHAEL PARISSI Active Y N AD <br />2220 - SM HW GEN <5 TONS/YR PR0539379 EE0000027 -CINDY VO Active Y N A Q D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andror 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 andlor Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />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 />EHD Staff: All, �/, �1 f 11 L Date ( / / / s' �I ? Account out: Date �_/ 22 <br />COMMENTS: �jLGj 1 /C&S�JGG��I.(► �° al ('AX.1 -br t1Z-/YtO�.iA - At Invoice#: <br />siteplan Aot 12ee � to b� .n om H1r1�Pp PO <br />9 6a.m. <br />