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Date tin 6/27/2014 8:37 56AN SAN JO/ 7IN COUNTY ENVIRONMENTAL HEAD DEPARTMENT Report#5021 <br /> Run by �� Paget <br /> Facility Information as of 6/27/2014 <br /> Record Selection Criteria: Facility ID FAGO13505 <br /> Make changesicorrections in RED ink. / <br /> INFORMATION CHANGE(date) 4' -17- <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed Tax ID : <br /> Owner ID OW0008975 Case Number: H09082 New Owner ID <br /> Owner Name CSK AUTO INC <br /> Owner DBA O'REILLY AUTO PARTS#3222 <br /> Owner Address 645 E MISSOURI AVE <br /> PHOENIX, AZ 85012 <br /> Home Phone Not Specified <br /> Work/Business Phone 602-265-9200 <br /> Mailing Address 3207 GREY HAWK CT STE 200 <br /> CARLSBAD, CA 92010 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0013505 10401895 <br /> Facility Name 2 r S -fL_ �z�1 <br /> Location 1200 W LATHROP RD <br /> MANTECA, CA 95336 <br /> Phone 209-239-9606 <br /> Mailing Address 3207 GREY HAWK CT STE 200 <br /> CARLSBAD, CA 92010 <br /> Care of <br /> Location Code 04-MANTECA Alt Phone <br /> BOIS District Fax <br /> APN 20203007 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name Isaak Basulto <br /> Title <br /> Day Phone 209-836-0206 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0022607 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name KRAGEN AUTO PARTS#3222 (Circle Ortel <br /> Account Balance as of 6/27/2014: $0.00 <br /> (Circle One) <br /> Transfer to Activelinactve <br /> Program/Element and Description Record ID Employee ID and Name status New Ownefl Delete <br /> 1921 -HMBP-Regular-Primary Location PR0520855 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO517567 EE0005642-MICHELLE HENRY Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO517569 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0517568 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532608 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,an yor project specific,PHS`EHD hourly charges associated with this facility <br /> or activity will Da billed to the party identHied as the OWNER on this form. I also certify that all operations will De performed in accordance with all applicable Ordinance Codes and it 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 vpt—�--Check Number Received}S) <br /> REHS: ETA" Date_/_/_ Account out: rr Date <br /> COMMENT <br />