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Date run 4/25/2014 1:45:04PR SAN JOIN COUNTY ENVIRONMENTAL HEALWEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 4/25/2014 <br /> Record Selection Criteria: Facility ID FA0018758 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) 0-Z5 -/`j <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0015425 New Owner ID <br /> Owner Name PETER KATZAKIAN <br /> Owner DBA AVANTI NUT <br /> Owner Address 12022 E COMSTOCK RD <br /> STOCKTON, CA 95215 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-479-3865 <br /> Mailing Address 12022 E COMSTOCK RD <br /> STOCKTON, CA 95215 ►"9"�`. <br /> Care of C.5-� fDs r,w <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0018758 77 ►01-(-r�'�ib 3 C, <br /> Facility Name AVANTI NUT <br /> Location-;= r-P Z-Zf+4g- cil <br /> STOCKTON, CA 95215 <br /> Phone 209-479-3865 xO <br /> Mailing Address 12022 E COMSTOCK RD <br /> STOCKTON, CA 95215 <br /> Care of <br /> Location Code Alt.Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 08902052 e- .-o�s +t.*, Sa, - 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 AR0033303 New Account ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner / Facility I Account <br /> Account Name PETER KATZAKIAN (Circle One) <br /> Account Balance as of 4/25/2014: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 1921 -HMBP-Regular-Primary Location PR0627674 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531653 Inactivf Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge Mat all site,andfor project specific,PHS'EHO hourly charges associated with this facility <br /> 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 Ordinance Codes andror Standards and State andror <br /> 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 <br /> Payment Type Check Number Received by <br /> REHS: Date LAU / Z5 / 11 f�y Account out: Date_/_/ <br /> COMMENTS: 1 —7.5— / 1 <br /> U�YLCSS amr1as 6ACARS iS �8�� Pe�Z+ IP-� <br />