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Date tun 9/10/'014 3:37:31 PA SAN JOT N COUNTY ENVIRONMENTAL HEAL�DEPARTMENT Report#5021 <br /> Run b} 12?3 Pagel <br /> Facility Information as of 9110/2014 <br /> Record Selection Criteria: Facility ID FA0004567 <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: 6 SSN/Fed Tax ID : <br /> OwnerID OW0018049 New Owner 10 : <br /> Owner Name OS Lodi LLC <br /> Owner DBA <br /> Owner Address 1000 LOWES BLVD <br /> MOORESVILLE, NC 28117 <br /> Home Phone..488•385=26715r -• /O 1 r2 -14 LtD — lik LRB I� <br /> Work/Business Phone 916-666-3955 <br /> Mailing Address 102 Segolily Court <br /> Lincoln, CA 95648 <br /> Care of TAX DEPT <br /> FACILITY FILE INFORMATION <br /> Facility lD/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 /> BOIS District 004-VOGEL, KEN Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name E <br /> Title <br /> Day Phone - <br /> Night Phone R49_3 411 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004346 C,2� New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name Tractor Supply Company,#1857 (Clyde One) <br /> Account Balance as of 9/10/2014: $376.50 <br /> (Circle One) <br /> ProgranvElemenl and Desodplion Rewrd ID Em to ee ID antl Name Status Transfer to Acdvell...h e <br /> P y New Owner? Delete <br /> 1615-RETAIL MKT 301-2000 SO FT(PREPKGD/LTD PF PRO500069 EE0001084-STEPHANIE RAMIREZ Inactive Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PRO520360 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO535764 EE0005642-MICHELLE HENRY Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0512347 EEo00o000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO510059 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,Ne undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also certify that all operations will be persormed in accordance with all applicable Ordinance Codes and'or Standards and State ands <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 Receive I <br /> REHS: Date_/ / Account out: Date <br /> COMMENTS: / <br />