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Date run 12/7/2016 3:50:40PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/7/2016 <br /> Record Selection Cntena: Facility ID FA0009710 <br /> Make changes/corrections 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 ID <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 /> BOIS 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 12/7/2016: $468.25 <br /> (Circle one) <br /> Transferto AcivaltacNe <br /> Program/Elemant and Description Record ID Employee ID and Name Slaws New Ovmer? Delete <br /> 1920-HMBP-Common Materials PRO519814 EE0008709-JAMIE LIMA Active Y N A I D <br /> ®SM HW GEN<5 TONS/YR PR0513999 EE0000005-FATINAH ZAREEF Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO511998 EE0000000-HAZ MAT SJC DES InactivE Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0509710 EE0000000-HAZ MAT SJC DES InactIvE Y N A I D <br /> 2840-AST EXEMPT FAC < 1,320 GAL PRO534950 EE0001422-ARIS VELOSO InactivE Y N A I D <br /> 4740-WASTE TIRE SITE-EXEMPT PRO523249 EE5555555-Garrett Alias-Backus InactivE Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534949 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 project specific,PHSrEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this forthl also certify that all operations will W performed in accordance with all applicable Ordinance Codes endor Standards and State andor <br /> 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 Received b <br /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: Invoice 9: <br /> i>--s r�.�r�_ _Tta.-�-.t' C7 t 7fil -Fv+_S f"F✓ . <br />