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Rate mn 7/21/`014 8:47:19Ak SAN J0 UIN COUNTY ENVIRONMENTAL HEALN?tri DEPARTMENT <br /> Roby 127$ Report*5021 <br /> Facility Information as of 7/21/2014 Pagel <br /> Record Selection Criteria: Facility ID FA0014331 <br /> Make changes/corrections in RED ink. _ U <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : <br /> Owner ID OW0011382 Case Number: H03965 New Owner to <br /> Owner Name Bridgestone Retail Operations, LLC <br /> Owner DBA MORGAN TIRE&AUTO <br /> Owner Address 802 S FIRST ST <br /> SAN JOSE, CA 95110 <br /> Home Phone Not Specified <br /> Work/Business Phone 630-259-9000 <br /> Mailing Address 333 East Lake Street Attn: Debra Hamlin <br /> Bloomingdale, IL 60108 <br /> Care of ELIANNE KEMPSELL/RISK <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0014331 10184607 <br /> Facility Name WHEEL WORKS#8249 <br /> Location 420 W LODI AVE <br /> LODI, CA 95240 <br /> Phone 209-339-9500 x <br /> Mailing Address BSRO 333 East Lake Street Attn: Debra Ha <br /> Bloomingdale, IL 60108 <br /> Care of Paul Madeiros (Store Manager) <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 04502047 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 AR0024355 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name Bridgestone Retail Operations, LLC (Circle One) <br /> Account Balance as of 7/21/2014: $0.00 <br /> (Circle One) <br /> Transfer to Aclivellnache <br /> PrograrvElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1921 -HMBP-Regular-Primary Location PRO521212 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2220-SM HW GEN<5 TONS/YR PRO523179 EE0001422-ARISVELOSO Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO519163 EE0000000-HAZ MAT SJC OES 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 PRO534349 Inactive Y N A I D <br /> BILLING arM COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anNor protect spec,PHSEHD hourly charges assoc aced with this reality <br /> or activity,will be billatl to the pant identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andVor Standards and State andbr <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 Received by <br /> REHSDate 1 /1�6& /\%_ Account out: Date <br /> COMMENTS: 14-k� <br /> 1_ � <br />