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Date run $/4/2010 2:52:56PM SAN JO/ :N COUNTY ENVIRONMENTAL HEA' DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8/4/2010 <br /> Record Selection Criteria: Facility ID FA0020194 <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 OW0016589 New Owner ID <br /> Owner Name RAJA, KHURAM S <br /> Owner DBA BEBE MART <br /> Owner Address 1169 S MAIN ST STE 101 <br /> MANTECA, CA 95336 <br /> Home Phone 209-923-2323 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1169 S MAIN ST STE 101 <br /> MANTECA, CA 95336 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0020194 G I <br /> Facility Name BEBE MART <br /> Location 231 W TENTH ST <br /> TRACY, CA 95376 <br /> Phone 209-923-2323 xHOME/CELL <br /> Mailing Address 1169 S MAIN ST STE#101 <br /> MANTECA, CA 95336 <br /> Care of KHURAM RAJA <br /> Location Code 03 -TRACY Alt Phone <br /> BOS District 005- ORNELLAS, LEROY Fax <br /> APN 23505105 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name KHURAM RAJA <br /> Title <br /> Day Phone 209-923-2323 xHOME/( <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0036054 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name BEBE MART (Circle One) <br /> Account Balance as of 8/4/2010: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Descnption Record ID Employee ID and Name Status New Owner /P061e <br /> 1615-RETAIL MKT<2000 SQ FT (PREPKGD/LTCPRO534919 EE0001699-JOHNNY YOAKUMve Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: ],the undersigned owner,operator or agent of same,acknowledge that all site,and r project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed tot .party identified as the OWNER on this to 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 /> 1 <br /> APPLICANT'S SIGNATURE:----- Date /�/ [C) <br /> Program Records to be TRANSFEREQ� '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Received b <br /> REHS: Date / / Account out: ---- Date / O <br /> COMMENTS: <br /> (06h�" 3/3� %*Uj p10 <br /> S ( l UG , 4 2 <br /> P �N <br /> ENS ERM��S�R�iCES <br /> \\eh-env\envision\reports\5021.rpt P <br />