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Date ran 3/282012 4:42:13Pk SAN JOx,.JIN COUNTY ENVIRONMENTAL HEAI DEPARTMENT Pagel sgzt <br /> Ran by Facility Information as of 3/28/2012� Pagel <br /> Record Selection Criteria: Facility ID FA0014331 <br /> Make changes/corrections in RED ink. Z <br /> INFORMATION CHANGE(date) -1 1 <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 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 S FIR Iz- <br /> 10 —� <br /> Care of <br /> V <br /> FACILITY FILE INFORMATION 3hnQ <br /> Facility ID FA0014331 1�erY1�S�l� <br /> Facility Name WHEEL WORKS IZt,K <br /> Location 420 W LODI AVE <br /> LODI, CA 95240 <br /> Phone 209-339-9500 <br /> Mailing Address 902-S-F4Rfr T <br /> Care of <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 ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name TIRES PLUS (Circle One) <br /> Account Balance as of 3/28/2012: $2,051.00 <br /> (Circle One) <br /> Transfer to Active/Inachwe <br /> ProgramlElement and Description Record ID Employee ID and Name Status <br /> New Omer' Delete <br /> 1921 -HMBP-Regular-Primary Location PR0521212 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2227-GEN 5<25 TONS PERMIT PRO523179 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARIPRO519163 EE0000000-HAZ MAT SJC IDES Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0522552 EE0002620-ALFONSO ARAMBULA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHPR0534349 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: L the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHS/EHO hourly charges associated Wim this <br /> facility or activity will be 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 and/or Standards and <br /> State arellor Federal laws. <br /> APPLICANT'S SIGNATURE: Date I / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date / Jr <br /> Payment Type Check Number eceived by <br /> RENS: Date / / Account out: Date <br /> COMMENTS: <br /> �e,55 <br /> 0A-7,v� —�f JZ�vsv �V-vvJC) — <br /> \teh-envWnvisionlreportM5021.rpt <br />