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Data run 11)9/2014 9:29:17Ah SAN JO. IN COUNTY ENVIRONMENTAL HEAI .DEPARTMENT Repon#502t <br /> Run by 1273 �/ V Pagel <br /> Facility Information as of 11/5/2014 <br /> Record Selection Criteria: Facility ID FA0022513 <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 OW0020036 New Owner ID <br /> Owner Name LRF Properties, LLC <br /> Owner DBA <br /> Owner Address <br /> Home Phone Not Specified <br /> Work/Business Phone 650-326-6179 <br /> Mailing Address 1120 Maybrown Avenue <br /> Menlo Park, CA 94025 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022513 10453774 <br /> Facility Name Tractor Supply Store#1303 <br /> Location 660 N Jack Tone Rd <br /> Ripon, CA 95366 <br /> Phone 615-440-4600 x <br /> Mailing Address 200 POWELL PLACE <br /> BRENTWOOD, TN 37027-7536 �— <br /> Care of Tractor Supply Company <br /> Location Code 05- RIPON Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN 25966055 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0041193 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name Tractor Supply Store#1303 (Circe One) <br /> Account Balance as of 11/5/2014: $0.00 <br /> (Circle One) <br /> Transfer to Aclive/Inachre <br /> ProgreMElement and Description Record ID Employee ID and Name Status New Owners Delete <br /> 1920-HMBP-Common Materials PR0539380 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0539379 EE0009488-JEFFREY WONG Active 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 speck,PHSrEHD hourly charges associated wth this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also cenity,that all operations will be performed in accordance with all applicable Ordinance Codes anNor 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 Re by <br /> REHS: Date_/ / Account out: �///,'�:'��,J/y�JDate�/_�/� <br /> COMMENTS: `^ <br /> / Wil. <br />