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LRun <br /> un 9/9/2004 9:43:05AM SAN JO 1UIN COUNTY ENVIRONMENTAL HEAT 3 DEPARTMENT <br /> Report#5021 <br /> Facility Information as of 9/9/20( Pagel <br /> Selection Criteria: Facility ID FA0014331 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION FILIEOWNERSHIP CHANGE(date) <br /> Owner iD OW0011382 Case Number: HO�� New Owner ID <br /> Owner Name TIRES PLUS <br /> Owner DBA WHEEL WORKS <br /> Owner Address 802 S FIRST ST <br /> SAN JOSE, CA 95110 <br /> Home Phone Not Specified <br /> Work/Business Phone 800-269-4424 <br /> Mailing Address 802S FIRST ST <br /> SAN JOSE, CA 95110 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0014331 <br /> Facility Name WHEEL WORKS <br /> Location 420 W LODI AVE <br /> LODI, CA 95240 <br /> Phone 209-339-9500 <br /> Mailing Address 802 S FIRST ST <br /> SAN JOSE, CA 95110 <br /> Care of <br /> Location Code LGD 1 APN: 0 4 Sb N Y"7 <br /> BOS District 004 SIC Code:9900 <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 TIRES PLUS Circle One) <br /> Account Balance as of 9/9/2004: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2244-PACT TRANSFER RECORD-OES PRO521212 EE0000000-HAZ MAT SJC IDES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SERVICE FPRO519163 EE0000000-HAZ MAT SJC IDES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0522552 EE0004636-GARRETT BACKUS Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowiedge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or actiyky will to billed to the party identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinate Codes ancVd,Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: •$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: •$155.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: 83s-9 11.C . Date / / Account out: Date <br /> COMMENTS: <br /> \\phs-ehsql-nt\a pps\envisions\reports\5021.rpt <br />