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FRun <br /> 4006 08 3:37:25PMSAN JO,' —TJIN COUNTY ENVIRONMENTAL HEAI Tti DEPARTMENT va 4006 Report <br /> Facility Information as of 2/5/20OW" Pagel <br /> Record Selection Criteria: Facility ID FA0016061 <br /> Make changes/corrections in RED ink or pencil. <br /> ' INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> Owner ID OW0012970 New Owner ID <br /> Owner Name KHAN, KASHIF N <br /> Owner DBA VALLEY SMOG & REPAIR <br /> Owner Address 206 FLORA ST <br /> LODI, CA 95240 <br /> Home Phone 209-200-3436 <br /> Work/Business Phone 209-334-0305 <br /> Mailing Address 206 FLORA ST <br /> LODI, CA 95240 <br /> Care of KHAN, KASHIF N <br /> FACILITY FILE INFORMATION =APN:043210277 <br /> Facility ID FA0016061Facility Name VALLEY SMOG & REPAIRLocation 26 N CHEROKEE LN STE C <br /> LODI, CA 95240Phone 209-334-0305 6c- DS <br /> Mailing Address LODI, CA 95240 — q3" <br /> Care of KHAN, KASHIF N <br /> Location Code 02-LODI BOS District 004-VOGEL, KEN <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0028024 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 2/5/2008: $23718 <br /> (Circle One) <br /> Transfer to Active/Inac e <br /> PmgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2220-SM HW GEN<5 TONSNR PR0523850 EE0001422-ARIS CACAPIT -Arthi YN A I D <br /> 2244-PACT TRANSFER RECORD-DES PR0526537 Inactive Y N A D <br /> 4740-WASTE TIRE SITE-EXEMPT PR0526828 EE5555555-Garrett Alias-Backus Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project spec,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the parry identified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes andfor Standards and <br /> Stale andfor Federal Laws. <br /> APPLICANT'S SIGNATURE: �'�It' "" Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: "$372.00= Amount Paid Date <br /> Payment Type Check Number Received by <br /> REHS: Date ! / Account out: Date <br /> COMMENTS: <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />