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i <br /> Daterun 2/17/2017 3:50:13PK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 2/17/2017 <br /> Record Selection Criteria: Facility ID FA0001410 <br /> Make changes/corrections in RED ink. <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 OW0001104 New Owner lD <br /> Owner Name KHANSHALI, YASIR <br /> Owner DBA OASIS MARKET& PRODUCE <br /> OwnerAddress 1350 FRENCH CAMP RD <br /> MANTECA, CA 95336 <br /> Home Phone 209-535-6213 <br /> Work/Business Phone 209-234-7555 <br /> Mailing Address 1350 FRENCH CAMP RD <br /> MANTECA, CA 95336 <br /> Care of KHANSHALI, YASIR <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0001410 <br /> Facility Name OASIS MARKET& PRODUCE <br /> Location 9542 S AIRPORT WAY <br /> MANTECA, CA 95336 <br /> Phone 209-234-7555 <br /> Mailing Address 9542 S AIRPORT WY <br /> MANTECA, CA 95336 <br /> care of KHANSHALI, YASIR <br /> Location Code 99-UNINCORPORATED A Alt Phone <br /> BOS District 003 - BESTOLARIDES, STEVE Fax <br /> APN 17708010 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name YASIR KHANSHALI <br /> Title <br /> Day Phone 209-535-6213 Cell <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID ARD001409 NewAcccunt ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name OASIS MARKET& PRODUCE (Circle One) <br /> Account Balance as of 2/17/2017: $258.00 <br /> (Circle One) <br /> Transfer to Actmellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1617-RETAIL MARKET>1000 SO FT W/FOOD PREP PRO161367 EE0004589-KADEANNE LINHARES Active Y N A I D <br /> 4242-WASTE WATER TX PLANT PRO527467 EE0004045-TED TASIOPOULOS Active Y N A I D <br /> 4633-TNC WATER SYSTEM WA0515536 EE0000003-VANCE WONG Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent a same,acknowledge that all site,and/or project specific,PHSEHD hourly charges associated with this facility <br /> or achiry will be billed to the party identified as the OWNER on Mis form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <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 /> EHD Staff: Date / / Account out: Date / / <br /> COMMENTS: <br /> IDVOICQ#: <br />