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Date run 1/27/2014 9:19:04AK SAN JOIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by <br /> Paget <br /> Facility Information as of 1/27/2014 <br /> Record Selection Criteria: Facility ID FA0014331 <br /> Make changeslcorrections in RED ink. I <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0011382 Case Number: H03965 New Owner ID <br /> Owner Name TIRES PLUS <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 800-269-4424 <br /> Mailing Address 2021 SUNNYDALE BLVD <br /> CLEARWATER, FL 33765 <br /> Care of ELIANNE KEMPSELURISK <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0014331 10184607 <br /> Facility Name WHEEL WORKS <br /> Location 420 W LODI AVE <br /> LODI, CA 95240 <br /> Phone 209-339-9500 <br /> Mailing Address 2021 SUNNYDALE BLVD <br /> CLEARWATER, FL 33765 <br /> Care of ELIANNEKEMPSELURISK <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 04502047 EMail: <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 to: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name TIRES PLUS (CimJeOne) <br /> Account Balance as of 1/27/2014: $0.00 <br /> 2 <br /> (Circle One) <br /> Transfer to Acdve/lnactve <br /> 9UNIFIED <br /> art and Description Record ID Employee ID and Name Status New Owner! Delete <br /> BP-Regular-Primary Location PR0521212 EE0008709-JAMIE DE LA ROSA Inactive Y N I D <br /> N 5<25 TONS PERMIT PRO523179 EED001422-ARTS CACAPIT Inactive Y N 1 D <br /> PROGRAM FAC STATE SURCHARGE F PR0519163 EEOOOOOOO-HAZ MAT SJC OES Inactive Y N 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 and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor protect specific,PHStEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also reality that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State aodor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date / I <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment T e Check Number Received by <br /> REHS: h� L� Date 1�_/ Account out: Date�l�/ i <br /> DDMQI EAV ji2o . <br />