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Date run 4/10/2017 9,05:49AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report M21 <br /> Run by Paget <br /> Facility Information as of 4/10/2017 <br /> Record Selection Criteria: Facility ID FA0009710 <br /> Make changeslcorrections 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 OW0015140 New Owner lD <br /> Owner Name KHAN, KASHIF <br /> Owner DBA VALLEY SMOG & REPAIR <br /> Owner Address 325 E KETTLEMAN LN 325 <br /> LODI, CA 95240 <br /> Home Phone 209-334-0305 <br /> Work/Business Phone Not Specified <br /> Mailing Address 325 E KETTLEMAN LN#325 <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0009710 10182833 <br /> Facility Name VALLEY SMOG & REPAIR <br /> Location 325 E KETTLEMAN LN 325 <br /> LODI, CA 95240 <br /> Phone 209-334-0305 <br /> Mailing Address 325 E KETTLEMAN LN#325 <br /> LODI, CA 95240 <br /> Care of <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004-WINN, CHARLES Fax <br /> APN 04727016 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 AR0016710 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name VALLEY SMOG & REPAIR (Circle One) <br /> Account Balance as of 4/10/2017: $2,474.42 <br /> (Circe One) <br /> Transfer to Adivelasetve <br /> Progrem/Element and Description Record 10 Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO519814 EE0008709-JAMIE LIMA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0511998 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2227-GEN 5<25 TONS PERMIT PRO513999 EE9999998-ONE VACANT I Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FE PR0509710 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2840-AST EXEMPT FAC <1,320 GAL PRO534950 EE0000030-AARON HANG Inactive Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0523249 EE5555555-GarrettAlias-Backus Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0534949 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,PHS/EHD hourly charges associated with this facility or 1 <br /> be billed to the pally identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor Federal Laws. <br /> APPLICANT'S 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 Receive//aa <br /> EHD Staff: Date / / Account out: /t Date <br /> COMMENTS: <br /> Invoi7 <br /> t � d�/- N"or� <br /> Icu� � �( � ZZ� G �✓�� d,, I.tA Yl � <br />