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- S <br /> [Ran <br /> ale Ian 4/4/2014 8:27:46W SAN JOA*IN COUNTY ENVIRONMENTAL HEAL�EPARTMENT <br /> by Report#5021 <br /> Facility Information as of 4/4/2014 Pagel <br /> Record Selection Carl Faddy ID FA664331 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> 7•-�'IW <br /> OWNER FILE INFORMATION Number of facilities for this owner: OWNERSHIP CHANGE(date) <br /> 1 SSN/Fed Tax ID <br /> Owner to OW0011382 Case Number: H03965 New Owner lo : <br /> Owner Name TIRES PLUSi TOrYPrr�e <br /> Owner DBA MORGAN TIRE&AUTO W Am4t,,,u__,t;,o <br /> Owner Address 802 S FIRST ST 2 C M ll0 <br /> SAN JOSE, CA 95110 I_o7`r l CA 5142 <br /> Home Phone Not Specified 109 4'101360 <br /> Work/Business Phone 800-269-4424 "4 - t} 10 <br /> Mailing Address 2021 SUNNYDALE BLVD _T1.0^ 5 W Leat _ <br /> CLEARWATER, FL 33765 Leal t_CA ��4b <br /> Care of ELIANNE KEMPSELURISK 1n/�11r2 Tt YY'usFe <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0014331 10,184,607 <br /> Facility Name WHEEL WORKS <br /> Location 420 W LODI AVEI& VJ- I_ayyj; <br /> LODI, CA 95240 <br /> Phone 209-339-9500 <br /> Mailing Address 2021 SUNNYDALE BLVD I-�'�`Q>, W. LeftAve . <br /> CLEARWATER, FL 33765 'Ie`I31,',; } CA g5�1540 <br /> Care of ELIANNEKEMPSELURISK rv`11� �Or(eN{�L <br /> Location Code 02 - LODI AR Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 04502047 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name ►�',fin\the. Torrei,. +e <br /> Title 01 JAIE(Z <br /> Day Phone ,',1, 4_t{+�ta <br /> Night Phone �.D� a410—1'3FA <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0024355 New Account ID: <br /> Mail Invoices to Owner Mail invoices to: Owner / Facility I Account <br /> Account Name TIRES PLUS (circle one) <br /> Account Balance as of 4/4/2014: $248.00 <br /> (Circle One) <br /> Transfer to ActivednacNe <br /> Program/Element and Description Record ID Employee ID and Name Stars New Owner) Delete <br /> 1921 -HMBP-Regular-Primary Location PR0521212 EE0008709-JAMIE DE LA ROSA Inactive Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO523179 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0519163 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO522552 EE0009000-HARPRIT MATTU Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534349 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges associated with this facility <br /> cractivity will be billed to the party identified as the OWNER on thisfonn. I also certify that all operations will be performed in accordance Withal]applicable Ordinance Codes andfor Standards and State andor <br /> Federal Law <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date I / <br /> Water System to be TRANSFERED: Amount Paid Date / / <br /> Payment Typ Check Number Recety <br /> REHS: i Date / /� Account out: Date__7_/ 1 d <br /> COMMENTS: 4�w1 . TLW4 � ,Wi (7I1/��/`a•L- <br />