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Date run 3/15/2018 9:51:30AR SAN JOAQUINCOUNTV ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by r Pagel <br /> Facility Information as of 3/15/2018 <br /> Record Selector,Criteria: Fadliry ID FA0014882 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) _ — '' 20 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN/Fed lax ID : �. <br /> Owner ID OW0007639 Case Number: H05039 Nee�w,0 neer lD : <br /> Owner Nam-�(AN-Ch� -E .�Tzvc I rl`/ A `44yL{F'Gi 5y'Q <br /> Owner DBA GIANT DISCOUNT TIRE INC <br /> Owner Address 330 E KETTLEMAN LN /g0j) H ! 2 <br /> LODI, CA 95240 VQ l l 1 0 Gtr _ 9 59 / <br /> Home Phone Not Specified 5 S O <br /> Work/Business Phone 9 2 <br /> Mailing Address 330 E KETTLEMAN LN <br /> LODI, CA 95240-5981 <br /> Care of VAN OGLE, STEVE <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0014882 <br /> Facility Name GIANT DISCOUNT TIRE <br /> Location 330 E KETTLEMAN LN <br /> LODI CA 95240 <br /> Phone 209-369-8228 <br /> Mailing Address 330 ETTLEMAN LN <br /> LODI, CA 95240-5981 <br /> Care of VAN OGLE, STEVE <br /> Location Code 02- LODI Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 06206052 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0025408 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner Facili / Account <br /> Account Name GIANT DISCOUNT TIRE D�� SK�3 roeOr,e) <br /> Account Balance as of 3/15/201 1,611.20 'i (d (Circle one) <br /> Transterto Active/Inamve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO621898 EE0008709-JAMIE LIMA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PR0541385 EE9999998-ONE VACANTI Active N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO541492 EE0009000-HARPRIT MATTU Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,anclor project spe iitc,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form I also candy that all operations will be performed in accordance with all applicable Ordinance Codes anovor Standards and State anti <br /> Federal Laws. C '7�,, <br /> APPLICANT'S SIGNATURE: Dat 3/ �J / G✓/i <br /> Program Records to be TRANSFERED: '$25.00= Amou7 Paid �1�q ^ ate <br /> Water System to be TTNSFERE : Am un aid Date _/ l� <br /> Payment Type Check Number 4, S ` Received TPr AY �p#� <br /> EHD Staff: C�.1�1' � Date / / Account out: Date <br /> COMMENTS: !q -t n !I�` �' Invoice#: S <br /> !V go�V� SAN 15 2018 <br /> a�-o = �- IRO 'V COU <br /> WEALTH 0EPgR �N�l' <br />