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Date tin 10/17/2014 9:22:54A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Repo4#5021 Rin by 1273 Pagel Facility Information as of 10/17/2014 Record Selection Catena Facility ID FA0004567 O Make changerlcorrections in RED ink. C3 INFORMATION CHANGE(date) OWNERSHIP CHANGE(date) OWNER FILE INFORMATION Number of facilities for this owner: 10 SSN/Fed Tax ID Owner ID OW0018049 New Owner ID Owner Name OS Lodi LLC Owner DBA Owner Address 1000 LOWES BLVD MOORESVILLE, NC 28117 Home Phone 615-4404600 Work/Business Phone 209-369-5528 Mailing Address 102 Segolily Court Lincoln, CA 95648 Care of TAX DEPT FACILITY FILE INFORMATION Facility ID/CERS ID FA0004567 10181661 Facility Name Tractor Supply Company, #1857 Location 360 S CHEROKEE LN LODI, CA 95240 Phone 209-369-5528 x Mailing Address 5401 Virginia Way Brentwood, TN 37027 Care of Tractor Supply Company Location Code 02 - LODI Alt Phone BOS District 004 -VOGEL, KEN Fax APN EMail EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name BRIAN SPEARS Title Day Phone 209-440-4600 Night Phone 615-440-4115 ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0004346 New Account ID: Mail Invoices to Account Mail Invoices to: Owner / Facility / Account Account Name Tractor Supply Company#1857 (Cirde One) Account Balance as of 10/17/2014: $376.50 (Circle One) Traniferfo Adivellnadve Program/Element and Desmpfion Record ID Employee ID and Name Status New Owner? Delete 1920-HMBP-Common Materials PR0520360 EE0008709-JAMIE DE LA ROSA Active Y N A I D 2220-SM HW GEN<5 TONS/YR PR0535764 EE0005642-MICHELLE HENRY Active Y N A I D 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512347 EE0000000-HAZ MAT SJC OES Inactive Y N A I D 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510059 EE0000000-HAZ MAT SJC OES Inactive Y N A I D ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533774 Inactive Y N A 1 0 BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor projed specific,PHSfEHD hourly charges associated with Nis facility or activity will be billed to the parry identified as the OWNER on this form. I also certify that all operations will be performed In accordance with all applicable Ordnance Codes ander Standards and State and« Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: "$25.00= Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received by REHS: Date_/ / Account out: Date / / COMMENTS'.