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Date run 7/25/2013 10:03:49AI <br /> Run by SAN JC."iUIN COUNTY ENVIRONMENTAL HEA_^F;DEPARTMENT Report#5021 <br /> Facility Information as of 7/25/2013 Paget <br /> Record selection criteria: Facility ID FA0014331 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) -_ <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) _- <br /> Owner IDSSN/Fed Tax OW0011382 Case Number: H03965 New Owner ID 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 lD/CERS ID FA0014331 10,184,607 <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 ELIANNE KEMPSELURISK <br /> Location Code 02 - LODI Alt Phone <br /> BOIS 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 ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name TIRES PLUS (Circle One) <br /> Account Balance as of 7/25/2013: $0.00 <br /> (Circle One) <br /> Transfer to Activerinactve <br /> Progra vElement 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 AD <br /> 2227-GEN 5<25 TONS PERMIT PRO523179 EE0001422-ARTS CACAPIT Active Y N A 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 EE0002620-ALFONSO ARAMBULA Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534349 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHO hourly charges assoaated with this reality <br /> or activity wilt be billed to the party identified as the OWNER on this form 1 also certify that all operation°will be performed In accordance with all applicable Ordinance Codes arauw Standards and State endo, <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 / I <br /> Payment Type Check Number / fie / Account out: Receiv <br /> REHDate <br /> S Date<�Lnll1 YYl1E� y-,�W1'rYLF�. LTl <br /> COMMENTS: <br />