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Date run 8/11/2014 2:48:41 Ph SAN JOAWN COUNTY ENVIRONMENTAL HEAL*DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/11/2014 <br /> Record Selection Criteria: Facility ID FA0021606 <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 OW0017767 New Owner ID <br /> Owner Name EBRIHIMI, RAZER <br /> Owner DBA LIVING INK <br /> Owner Address 4271 COUNCIL TRL <br /> COPPEROPOLIS, CA 95228 <br /> Home Phone 209-839-6701 <br /> Work/Business Phone Not Specified <br /> Mailing Address 4271 COUNCIL TRL <br /> COPPEROPOLIS, CA 95228 <br /> Care of EBRIHIMI, RAZER <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021606 <br /> Facility Name LIVING INK(EBRIHIMI, RAZER) <br /> Location 2189 N TRACY BLVD <br /> TRACY, CA 95376 <br /> Phone 209-839-6701 <br /> Mailing Address 2189 N TRACY BLVD <br /> TRACY, CA 95376 <br /> Care of EBRIHIMI, RAZER <br /> Location Code 03-TRACY Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name EBRIHIMI, RAZER <br /> Title <br /> Day Phone 209-839-6701 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0039144 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name LIVING INK(EBR MI, RAZER) (Circle One) <br /> Account Balance as of 8/11/2014: $,37 0 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4110-BODY ART PRACTITIONER REGISTRATION PR0537533 EE0002620-ALFONSO ARAMBULA rAetide' Y N AD <br /> 4121 -BODY ART FACILITY-STERILIZATION PR0537534 EE0002620-ALFONSO ARAMBULA --'ActlVB 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 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 /> Paymen Type Check Number Receiv <br /> REHS: &'tAo ����� Date / �l / tl Account out: Date <br /> COMMENTS: <br /> C-6 - 'AlkO G<)� �-tlal <br />