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Report 05021 <br /> Date nm 9/18/2015 9:27:32AN SAN JUIN COUNTY ENVIRONMENTAL HE4W DEPARTMENT Pagel <br /> Run by Facility Information as of 9/18/2015 <br /> ------------- <br /> Record Selection Criteria: Facility ID FA0018760 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(dale) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number offacilities for this owner : 1 SSN/Fed Tax 10 <br /> owner ID OW0015427 New Owner ID <br /> Owner Name O'Reilly Auto Enterprises, L.L.C. <br /> Owner DBA O'REILLYAUTO PARTS <br /> Owner Address 645 E MISSOURI AVE 194 <br /> PHOENIX,AZ 85012 <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 FA0018760 10401910 <br /> Facility Name O'Reilly Auto Parts#3810 <br /> Location 1551 W Main St <br /> Ripon, CA 95366 <br /> Phone 209-599-1546 x <br /> Mailing Address 3E Company, Regulatory Dept./O'Reilly Auto, <br /> Carlsbad, CA 92010 <br /> Care of O'Reilly Auto Enterprises, L.L.C. <br /> Location Code 05-RIPON Alt Phone <br /> BOIS District 005- ELLIOTT, BOB Fax <br /> APN 259-660-54 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> New Account ID: <br /> Account ID AR0033305 <br /> Mail Invoices to Account Mail Invoices to: Owner I Facility / Account <br /> (Circe One) <br /> Account Name 3E Company, Regulatory Dept./O'Reilly Auto Parts <br /> Account Balance as of 9/18/2015: $0.00 (circle one) <br /> Transfer to Activennacive <br /> Program/Element and Description Record ID Employee ID and Name <br /> Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PR0527676 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONSNR PR0535769 EE0005642-MICHELLE HENRY Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0534045 <br /> Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ancyor project speck,PHStEHD 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 end?or Standards and State andior <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 /> EHD Staff: <br /> Date AmoDate <br /> Account out: <br /> COMMENTS: Invoice#: <br />