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Date run 5/21/2014 11:27:07AI SAN J( AN COUNTY ENVIRONMENTAL HE/ DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 5/21/2014 <br /> Record Selection Criteria: Facility ID FA0021656 <br /> Make changesicorrections 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 OW0017818 New Owner ID <br /> Owner Name YUSUFI, SARA S <br /> Owner DBA SNACK SHACK <br /> Owner Address 2729 JACKSON AVE <br /> TRACY, CA 95377 <br /> Home Phone 209-597-7591 <br /> Work/Business Phone 209-640-8454 <br /> Mailing Address 2729 JACKSON AVE <br /> TRACY, CA 95377 <br /> Care of YUSUFI, SARA <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021656 <br /> Facility Name SNACK SHACK <br /> Location 3200 NAGLEE RD STE 322 <br /> TRACY, CA 95304 <br /> Phone 209-640-8454 <br /> Mailing Address 3200 NAGLEE RD STE 322 <br /> TRACY, CA 95304 <br /> Care of YUSUFI, SARA <br /> Location Code 03 -TRACY Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN 21205043 EMaV <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name YUSUFI, SARA <br /> Title <br /> Day Phone 209-640-8454 <br /> Night Phone 209-597-7591 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID ARO 977 New Account ID: <br /> Mail Invoices to F Clllty _ --- Mail Invoices to: Owner / Facility / Account <br /> Account Name S AGk SHACK (Circle One) <br /> Account Balance as of 5/ 014: $174.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1620-RETAIL MKT 26-300 SO FT(INCIDENTAL FOOD: PR0537610 EE0001420-MELISSA NISSIM Active Y N A (�[ JD <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 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 and/or Standards and State and/or <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 by <br /> RENS: Date / 2-11 1 Account out: Date / / Z� <br /> COMMENTS: <br /> y ou.>r tet-( Leai .cVe Y/Yy o k-k /��-�/s �Z1 <br /> reI/(/- 1-�� V w��K ✓`tel/ /v` -V � I <br /> Sr 14v#-j C /6� <br />