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Date run ?1712008 1:51:06PA SAN JC IUIN COUNTY ENVIRONMENTAL HE h' `H DEPARTMENT Report A 5U21 <br /> . Run'oy "r � ��, �..rYr Pagel <br /> Facility Information as of 9/17/2008 <br /> Record Selection Criteria: Facility ID FA0001410 <br /> Make changes/corrections in RED ink or pencil <br /> FIL <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0001104 New Owner ID : <br /> Owner Name KHANSHALI, YASIR <br /> Owner DBA SA G \ ` <br /> Owner Addres D <br /> CROWS C,ci <br /> Home Phone 209-535-6213 <br /> f Work/Business Phone 209-234-7555 <br /> Mailing Address g DING RD <br /> Care of KHANSHALI, YASIR <br /> FACILITY FILE INFORMATION <br /> f Facility ID FA0001410 <br /> Facility Nam UCE _Cl) R5 <br /> Location 9542 S AIRPORT WAY <br /> MANTECA, CA 95336 <br /> Phone 209-234-7555 <br /> Mailing Address 9542 S AIRPORT WY <br /> MANTECA, CA 95336 <br /> Care of KHANSHALI, YASIR <br /> Location Code gg- UNINCORPORATED P Alt Phone <br /> BOS District 003 - MOW, VICTOR Fax <br /> APN 17708010 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name YASIR KHANSHALI <br /> Title <br /> Day Phone— <br /> �, � 2 S <br /> ` Night Phone <br /> 3 ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0001409 New Account ID <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility I Account <br /> Account Name SAM'S MARKET & PRODUCE (circle one) <br /> Account Balance as of 911712008: $tM69z5Q <br /> (Circle One) <br /> l Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owneo Delete <br /> 1615-RETAIL MKT X2000 SQ FT (PREPKGD 1 LTCPRO161367 EE00010B4-STEPHANIE RAMIREZ Active Y N A I D <br /> 4242-WASTE WATER TX PLANT PR0527467 EE0004045-TED TASIOPOULOS Active Y N A I D <br /> 4616-TNC WATER SYSTEM-CURFFL WA0515536 EE0003027-MINH NGUYEN Active 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,PHSIEHO hourly charges associated with this <br /> facility or activity wilt be bitted to the party identified as the OWNER on this form. 1 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 /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: "$20.00= 3 Amount Paid Date 1 1 <br /> Water System t NFERED: $372,00 Amount Paid Date <br /> Pay nt Type �Rllult�r / ! <br /> Received by <br /> REHS: Date LY I1 Account out: _ 2� Date <br /> COMMENTS: <br /> SEP ? 10O <br /> Ilphs-ehsql-ntlappslenvisionslreports15021.rpt <br />