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Date run 7/23/2015 4:28:51 Plv SA AQUIN COUNTY ENVIRONMENTAL OLTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/23/2015 <br /> Record Selection Criteria: Fauliry ID FA0012714 <br /> Make changes/corrections 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 OW0020655 New Owner ID <br /> Owner Name PIJL,ADAM <br /> Owner DBA KEES INC <br /> OwnerAddress 4245 FIVE MILE DR <br /> STOCKTON, CA 95219 <br /> Home Phone 209-200-6628 <br /> Work/Business Phone 209-957-2850 <br /> Mailing Address 4245 FIVE MILE DR <br /> STOCKTON, CA 95219 <br /> Care of PIJL,ADAM <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0012714 10184329 <br /> Facility Name DAVIDS PIZZA <br /> Location 900 W BENJAMIN HOLT DR <br /> STOCKTON, CA 95207 <br /> Phone 209-957-2850 <br /> Mailing Address 900 W BENJAMIN HOLT DR <br /> STOCKTON, CA 95207 <br /> Care of PIJL,ADAM <br /> Location Code 99- UNINCORPORATEDA Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 09741046 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name PIJL,ADAM <br /> Title <br /> Day Phone 209-957-2850 <br /> Night Phone 209-200-6628 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0021191 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name DAVIDS PIZZA (Circle One) <br /> Account Balance as of 7/23/2015: $0.00 <br /> (Circle One) <br /> Transfer to Acliva'Inacha, <br /> Program/Element and Descrption Record ID Employee ID and Name Status New Owner? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PR0516624 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0529921 EE0000006-HAZA SAEED Active Y N A I D <br /> 3116-STORMWATER INSPECTION-FOOD PR0522863 EE0000149-RAYMOND BORGES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0534091 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project speck,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. 1 also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws. <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: Invoice#: <br />