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Date run 3/18/2010 10:59:31AI SAN JOA "IN COUNTY ENVIRONMENTAL HEALT—DEPARTMENT Report#5021 <br /> Run by-' 5290 <br /> Facility Information as of 3/18/201 ` Paget <br /> Record Selection Criteria: Facility ID FA00I 8425 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0015140 New Owner ID <br /> Owner Name ANWAR, REHAN/KHAN, KASHIF <br /> Owner DBA VALLEY SMOG & REPAIR <br /> Owner Address 923 S CHEROKEE LN <br /> LODI, CA 95240 <br /> Home Phone 209-334-0305 <br /> Work/Business Phone Not Specified <br /> Mailing Address 923 S CHEROKEE LN <br /> LODI, CA 95240 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0018425 V <br /> Facility Name VALLEY SMOG & REPAIR <br /> Location 923 S CHEROKEE LN <br /> LODI, CA 95240 <br /> Phone 209-334-0305 <br /> Mailing Address 325 E KETTLEMAN LN <br /> LODI, CA 95240 <br /> Care of REHAN ANWAR <br /> Location Code 02- LODI Aft Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 04739006 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name REHAN ANWAR <br /> Title <br /> Day Phone 209-334-0305 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0032529 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name VALLEY SMOG & REPAIR (Cirde One) <br /> Account Balance as of 3/18/2010: $362.00 <br /> -U U (Circle One) <br /> Transfer to Active/InaWo <br /> Program/Element and Description Record ID Employee ID and Name Stews New Owner? Delete <br /> 2220-SM HW GEN<5 TONS/YR PR0527266 EE0001422-ARIS CACAPIT Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-CES PRO528777 Active Y N A D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO527217 EE5555555-Garrett Alias-Backus Active Y N A D <br /> ERSC-ELECTRONIC REPORTING SURCHARGE PRO531579 Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or <br /> id <br /> activity Will be billed to the partyentified as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date / / <br /> WaterSystem SFERED: 00= Amount Paid Date <br /> Pa ype Check Number Received b <br /> R HS: � Date2�l it) Account out: Date 3 <br /> COMMENTS: <br /> \\eh-env\envision\reports\5021.rpt <br />