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Date.run 10/13/2020 3:51:46P SAN,'OAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/13/2020 <br /> Record Selection Criteria: Facility ID FA0017710 <br /> Make changestcorrections 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 OW0014535 New Owner ID <br /> Owner Name WITHROW, CHRIS <br /> Owner DBA ANKA NORTHSTAR <br /> OwnerAddress 1875 WILLOW PASS RD <br /> CONCORD, CA 94520 <br /> Work/Business Phone Not Specified <br /> Alternative Phone 925-825-4700 <br /> Mailing Address 1875 WILLOW PASS RD <br /> CONCORD, CA 94520 <br /> Care of <br /> FACILITY FILE INFORMATION APN 24130052 <br /> Facility ID/CERS ID FA0017710 <br /> Facility Name ANKA NORTHSTAR <br /> Location 401 S AIRPORT WAY <br /> MANTECA, CA 95336 <br /> Phone 209-983-4090 <br /> Mailing Address 401 S AIRPORT WAY <br /> MANTECA, CA 95336 <br /> Care of <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name PAM SHORT <br /> Title <br /> Day Phone 209-825-1350 <br /> Night Phone 209-983-4090 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0030879 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name ANKA NORTHSTAR (Circle One) <br /> Email invoice to(up to 2 emails) <br /> Email permit to(up to 2 entails) <br /> Account Balance as of 10/13/2020: $613.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4242-WASTE WATER TX PLANT PR0526172 EE0000034-NASEEM AHMED 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,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 Ord odes or landards and State ancifor <br /> Federal Laws. J A� <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 /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: <br /> nvoice#: <br /> U <br />