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Date run 10/16/2007 2:59:03F SAN JO JUIN COUNTY EFYVIRdNMENTAL HEA -4 DEPARTMENT Report#5021 <br /> Run by 404 Pagel <br /> Facility Information as of 10/16/2b11117 <br /> Record Selection Criteria: Facility ID FA0001410 <br /> Make changeslcorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0001104 New Owner ID <br /> Owner Name KHANSHALI, YASIR <br /> Owner DBA SAM'S MARKET& PRODUCE <br /> Owner Address 9952 CROWSLANDING RD <br /> CROWS LANDING, CA 95313 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 9952 CROWSLANDING RD <br /> CROWS LANDING, CA 95313 <br /> Care of KHANSHALI, YASIR <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0001410 <br /> Facility Name SAM'S MARKET& PRODUCE <br /> Location 9542 S AIRPORT WAY <br /> MANTECA, CA 95336 <br /> Phone 209192=06M <br /> Mailing Address 9542 S AIRPORT WY <br /> MANTECA, CA 95336 <br /> Care of SAM'S MARKET/YASIR KHANSHALI <br /> Location Code 99 - UNINCORPORATED AREA APN:17708010 <br /> BOS District 003- MOW, VICTOR SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0001409 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name SAM'S MARKET& PRODUCE (Circle One) <br /> Account Balance as of 10/16/2007: $-280.50 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1615-RETAIL MKT<2000 SQ FT (PREPKGD/LTEPRO161367 EE0008373-JOHN JACKSON 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,PHSIEHD hourly charges associated with this <br /> facility 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 Ordinace Codes and/or Standards and <br /> State andlor Federal Laws. a �� <br /> APPLICANT'S SIGNATURE: A-r-rA�bE'-�1 Date / ! <br /> Program Records to be TRANSFERED: '$20.00 W Amount Paid Date 1 I <br /> Water System to be TRANSFERED: "$372.00= Amount Paid Date ! 1 <br /> Payment Type Check Number Recei�vj`d�b� <br /> RENS: Date I I Account out! i� Date fy/-16 I <br /> COMMENTS: <br /> [AJV <br /> 11phs-ehsgl-ntlappslenvisionslreports15021.rpt <br />