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RECEIVED <br /> JAN 20 2011 <br /> SAN JOAQUIN COUNTY <br /> Del•'un 11115/2010 3:50.55P SAN JOA(� NCOUNTYLvNVIRONMENfALHEALT, EPA16 IVILKUEN 4w"ES <br /> @ate v-� Pya1 <br /> Facility Information as of 11/1312010 <br /> PAC"Sion on Cl0.Wa it,ity 10 F11,11 <br /> }I, I3J / � D�r T �AchaINFORMATI N in RED ink. <br /> /U71/E'' C. ! INFORMATION CHANGE(date) d <br /> FNV7�� ZQfQ ® �,+ OWNERSHIP GRANGE(date) <br /> OWNER FILE INFORMATI y ""y /�s/$N/ped Tax 10 <br /> Owner ID yy000124 n�CTy '- New Owner 10 : t��OD�1t <br /> Owner Name �DfeL6ASM S/I. 3'.E![o-. G[Ln II6oT+i✓ RJEStMA�d( <br /> ,ZT <br /> Owner DBA Sac <br /> Owner Address CR e .. <br /> a TON, GA 07 <br /> Home Phone Not led <br /> WOrklSvsiness PhOns 209 74-7 2 <br /> Mating Address e/34/J St - �j,L/p <br /> S 07 S f.c ril grlgV <br /> Care of 5 4.�r -t,(u <br /> FACILITY FILE INFORMATION <br /> Facility IO FA0001587 <br /> Facility Name GHINGGIS KHAN <br /> Location 2233 GRAND CANAL BLVD 117 <br /> STOCKTON, CA 95207 <br /> Phone 209.952-3137 <br /> Mailing Address 2233 GRAND CANAL BLVD#117 <br /> STOCKTON, CA 95207 <br /> Care of SHIH, RONNIE <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002- RUHSTALLER, LARRY Fax <br /> APN 11011006 Email: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name 5Hft,- 0NIgfE S-4'4' S-/ao'-54,2* /V44-r-roe-IJ �JfE('R <br /> Tide <br /> Day Phone 2QQ-4.7 2 <br /> Night Phone 209-474-7332 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account b AR0001586 New Account ID: <br /> Mad Invoices to Facility Mail Invoices to: Owner / Facility y Account <br /> Account Name GHINGGIS KHAN tew.0^•I <br /> Account Balance as of 11/1512010' $0.00 <br /> Keel.Coy <br /> ;oeo ro Aclie/marn. <br /> ProgMnl w <br /> ramEn0ewlglw Rocord go <br /> ID Emyw ws N.w Own✓! Oto end Nsme SloeI.Ie <br /> 1626-RESTAURANTIUAR 101 +SEATS PRO160493 EE0003361-MARIBEL FLOHRSCHU14dlve Y N A 1 D <br /> 2244-PACT TRANSFER RECORD-OES PRO528756 Active Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PRO533421Active Y N A I D <br /> BILLING SMCDMPUANCE ACKNOYA.EOGEMENT: I, a ultlenyrledpArr. > mor sem•,ac.mwMd6e Nal a1 mWandla prdlKl epecfe:,PHbIC-No no✓1y onxe+9 asoclgetl%0iIMa <br /> Iedsly w'se.vewl <br /> y .M diad to M perly ioerdef d as WNER m 1 M opermbnr W De Dodwm.d n ovn .M wsh M epwaDY Ormnac.Codes We"fi> .end <br /> 61ie"a-Fooluel Law.. <br /> APPLICANT'S SIGNATURE. - Data <br /> Program Records to be TRANSFERED• _'$25,00• Amount Paid Dale <br /> water System to be TRANSFERED: AmountPaid Dale_J_y <br /> Payment Type Check Number Recev y <br /> RENS: Dole Ago <br /> Account out Date <br /> COMMENTS <br /> \1eh­@nvlanv1slomrepodM5021,nit <br /> p0/Z0 39tld Hi-lV3H -N_N3VN021I/W3 0EI011191,60Z 11:60 ITOZ/0Z/I0 <br />