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Date run 12/24/2012 1:46:11F SAN J( UIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/24/2012 <br /> Record Selection Criteria: Facility ID FA0021623 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0005112 New Owner ID <br /> Owner Name SINGH, BACHITAR <br /> Owner DBA JAHANT FOOD N FUEL STOP <br /> Owner Address 24323 N HWY 99 <br /> ACAMPO, CA 95220 <br /> Home Phone 209-333-6000 <br /> Work/Business Phone 209-339-1874 <br /> Mailing Address PO BOX 2735 <br /> LODI, CA 95241 <br /> Care of SINGH, BACHITAR <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0021623 <br /> Facility Name JAHANT FOOD AND FUEL <br /> Location 24323 HIGHWAY 99 <br /> ACAMPO, CA 95220 <br /> Phone 209-327-2836 <br /> Mailing Address PO BOX 2735 <br /> LODI, CA 95241 <br /> Care of SINGH, BACHITAR <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 00516019 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SINGH, BACHITAR <br /> Title <br /> Day Phone 209-327-2836 <br /> Night Phone 209-333-6000 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0039177 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name ODIC ENVIRONMENTAL (Circle One) <br /> Account Balance as of 12/24/2012: $-875.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 2950-ENVIRON ASSESS PR0537557 EE0001699-JOHNNY YOAKUM Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: f,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHS/EHD 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 andfor Standards and State and/or <br /> Federal Laws. <br /> APPLICANTS 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 by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br />