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Date run 4/23/2013 11:31:19AI SAN J04vo4JIN COUNTY ENVIRONMENTAL HEAh,4 DEPARTMENT Report M21 <br /> Run by <br /> Facility Information as of 4/23/2013 Pagel <br /> Record Selection Criteria: Facility ID FA0010953 <br /> Make changesfcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0008953 Case Number: H09961 New Owner ID <br /> Owner Name TRI FORCE SOLUTIONS <br /> Owner DBA BIG O TIRES <br /> Owner Address 1129 W 11TH ST <br /> TRACY, CA 95376 <br /> Home Phone 209-836-2683 <br /> Work/Business Phone 209-836-9145 <br /> Mailing Address 1129 W 11TH ST <br /> TRACY, CA 95376 <br /> Care of AMARJIT DALE <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0010953 10,183,965 <br /> Facility Name BIG O TIRES <br /> Location 1129 W ELEVENTH ST <br /> TRACY, CA 95376 <br /> Phone 209-836-2683 <br /> Mailing Address 1129 W 11TH ST <br /> TRACY, CA 95376 <br /> Care of <br /> Location Code 03 -TRACY Alt Phone <br /> BOS District 005-ORNELLAS, LEROY Fax <br /> APN 23229068 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name AMARJIT(SINGH) DALE <br /> Title <br /> Day Phone 209-836-2683 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0017953 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name BIG O TIRES (Circle One) <br /> Account Balance as of 4/23/2013: $163.00 <br /> (Circle One) <br /> Transfer to Actnny'nai <br /> Progrann Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0536959 EE0002646-THUY TRAN Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATIOPPRO513241 EEOOOOOOO-HAZ MAT SJC DES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0610953 EE0002620-ALFONSO ARAMBULA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCH,PR0537009 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this facility <br /> or acu"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 and/or Standards and State andor <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 /> REHS: Date / I Account out: Date <br /> COMMENTS: <br />