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Date run 1/13/201412:12:49PI SAN XWIN COUNTY ENVIRONMENTAL HEA4 DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1/13/2014 <br /> Record Selection Criteria: Facility ID FA0016538 <br /> �� Make Chan NFOR rATION in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0000369 New Owner ID <br /> Owner Name Save Mart Supermarkets <br /> Owner DBA <br /> Owner Address 1800 STAMFORD AVE <br /> MODESTO, CA 95350 <br /> Home Phone 209-574-6299 <br /> Work/Business Phone 209-577-1600 <br /> Mailing Address 1800 Standiford Ave. <br /> Modesto, CA 95350 <br /> Care of SAVE MART SUPERMARKETS <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0016538 10421809 <br /> Facility Name Save Mart#94 <br /> Location 15240 S Harlan Rd <br /> Lathrop, CA 95330 <br /> Phone 209-858-4798 x <br /> Mailing Address 1800 Standlford Ave. <br /> Modesto, CA 95350 <br /> Care of Save Mart Supermarkets <br /> Location Code 07 - LATHROP Alt Phone <br /> BOS District 003 - BESTOLARIDES Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name AGAH, RAY <br /> Title <br /> Day Phone 209-8584798 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0029142 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name Save Mart#94 (Circle One) <br /> Account Balance as of 1/13/2014: $0.00 <br /> (Circle One) <br /> Transfer to Aclivellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1619-RETAIL MKT>1000 So FT(=/>2 DEPTS) PRO524635 EE0001420-MELISSA NISSIM Active Y N A I D <br /> ZSM HW GEN<5 TONS/YR PR0538347 EE0002646-THUY TRAIN Active Y N A I D <br /> - <br /> NG and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will he billed to the party identilied as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ander <br /> Federal Laws. <br /> APPLICANTS 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 Racel a by // <br /> REHS: k k.Nb+ Date I Q) t Account out: Date�/�//"" <br /> /1q-_ <br /> COMMENTS: <br /> 22,2_0 Vttcr c S <br /> wt( - purtwf' <br />