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Date run 9/30/2014 10:51:36AI SAN JO.`yN COUNTY ENVIRONMENTAL HEAL,....IIII)EPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/30/2014 <br /> Record Selection Cleans: Facility ID FA0004567 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 6 SSN/Fed Tax ID : <br /> Owner ID OW0018049 New Owner ID <br /> Owner Name OS Lodi LLC <br /> Owner DBA <br /> Owner Address 1000 LOWES BLVD <br /> MOORESVILLE, NC 28117 <br /> Home Phone 615-440-4600 <br /> Work/Business Phone 209-369-5528 <br /> Mailing Address 102 Segolily Court <br /> Lincoln, CA 95648 <br /> Care of TAX DEPT <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0004567 10181661 <br /> Facility Name Tractor Supply Company, #1857 <br /> Location 360 S CHEROKEE LN <br /> LODI, CA 95240 <br /> Phone 209-369-5528 x <br /> Mailing Address 5401 Virginia Way <br /> Brentwood, TN 37027 <br /> Care of Tractor Supply Company <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN EMail <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name ORCHARD SUPPLY HARDWARE <br /> Title KATE KOSCHEI <br /> Day Phone 619-677-0150 x3002 <br /> Night Phone 209-368-2500 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004346 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name Tractor Supply Company, #1857 (Circle One) <br /> Account Balance as of 9/30/2014: $376.50 <br /> \Q ZO (Circle One) <br /> Q\\ Transfer to (Circle OnNe <br /> e) <br /> jPmgralement and Description Rewrtl ID Employee ID and Name Status New Owne/! Delete <br /> AIL MKT 301-2000 SO FT(PREPKGD/LTD PF PR0500069 EE0001084-STEPHANIE RAMIREZ Inactive Y N A I D <br /> BP-Regular-Primary Location PRO520360 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 0-SM HW GEN<5 TONS/YR PRO535764 EE0005642-MICHELLE HENRY Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512347 EE0000000-HAZ MAT SJC OES Inactive Y N A 1 D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0510059 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533774 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,atdmowledge that all site,andor project spec,PHS/EHD hourly charges associated with this facility <br /> or activity will W billed to the party identified as the OWNER on this forth. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal La. <br /> APPLICANTS SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Ty Check Number Receiv <br /> REHS: t�� DD/a�tte��/ / /' �Account out:�� � (y1 Date <br /> COMMENTS: '�U�1 VV <br /> WJ r "'HCl COM• I m V '/M 1 v/t V"' r l� V"•W 1 r/I <br />