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Report 95021 <br /> Date DNr 6/5/2012 9:17:42AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Pagel <br /> R°" Facility Information as of 6/5/2012 <br /> Record Selection Critede: Facility ID FA0009097 <br /> - Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE e <br /> OWNER FILE INFORMATION SSN/Fed Tax ID : '1 /C® <br /> Owner ID OW0007097 Case Number: H01136 New Owner ID : V C <br /> Owner Name CRONIN, BILL]CHRISTENSEN, E <br /> Owner DBA BIG O TIRES#31 <br /> Owner Address 810 E YOSEMITE AVE VIRnA <br /> MANTECA, CA 95336 EALTH rte <br /> Home Phone 209-599-5104 _I MEL <br /> work/Business Phone 209-239-9591 <br /> Mailing Address 810 E YOSEMITE AVE <br /> MANTECA, CA 95336 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0009097 <br /> Facility Name BIG O TIRES#31 <br /> Location 810 E YOSEMITE AVE <br /> MANTECA, CA 95336 <br /> Phone 209-239-9591 <br /> Mailing Address 810 E YOSEMITE AVE <br /> MANTECA, CA 95336 <br /> Care of CRONIN, BILL <br /> Location Code 04-MANTECA Alt Phone <br /> BOS District 005-ORNELLAS, LEROY Fax <br /> APN 22118016 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION New Account ID: <br /> Account ID AR0016097 <br /> Mail Invoices to: Owner / Facility / Account <br /> Maillnvoicesto Facility (Circle One) <br /> Account Name BIG O TIRES#31 <br /> Account Balance as of 6/5/2012: $568.50 (Circle one) <br /> Transfer to Activenaactve <br /> PrograMElement and Description <br /> Record ID Employee ID and Name <br /> Status New Owner? Delete <br /> Y N A I D <br /> 1920-HMBP-Common Materials PRO513637 EE0002670-MICHAEL NAID I Active Y N A I D <br /> 2220-SM HW GEN<5 TONSIYR PR0513637 EE0002670-MUNIAPPA NAIDU Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHOR EE0000000-HAZ MAT SJC CES Inactive y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHAR(PRO509097 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO522392 EE0002620-ALFONSO ARAMBULA Active Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHrPR0533643 erWlor Project specific <br /> ,PHSIEHD hourly chargee associated with this facility <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,Ne undersigned owner,operator or, <br /> 'giant of same,acknowledge that all site, 1 <br /> or activity will be billed to me Pang identified as the OWNER on this form I also certify that all operations will be Performed in accordance with all applicable Ordinance Codas and/or Stantlards arM Stats angor <br /> Federal Laws. <br /> Date <br /> APPLICANT'S SIGNATURE: <br /> Amount Paid Date <br /> `rogram Records to be TRANSFERED: '$25.00= ate <br /> star System System to be TRANSFERED: Amount Paid Received Date <br /> ymentType Check Number - Date <br /> iS: <br /> Date_/—/— Account out: <br /> MENTS: <br />