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Date run 7/28/2015 9:12:45AN SAN JOAQtjlN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 7/28/2015 <br />Record Selection Criteria: Facility ID FA0002545 <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 <br />Owner ID <br />OW0000773 <br />Owner Name <br />HAPPY BEES INC <br />Owner DBA <br />PERKOS CAFE <br />Owner Address <br />2122 PATTERSON RD <br />Phone <br />RIVERBANK, CA 95367 <br />Home Phone <br />209-863-1002 <br />Work/Business Phone <br />209-832-4675 <br />Mailing Address <br />2122 PATTERSON RD <br />Location Code <br />RIVERBANK, CA 95367 <br />Care of <br />HAPPY BEES INC <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0002545 <br />Facility Name <br />PERKOS CAFE <br />Location <br />1321 W ELEVENTH ST <br />TRACY, CA 95376 <br />Phone <br />209-832-4675 <br />Mailing Address <br />2122 PATTERSON RD <br />RIVERBANK, CA 95367 <br />Care of <br />HAPPY BEES INC <br />Location Code <br />03 -TRACY <br />Bos District <br />005 - ELLIOTT, BOB <br />APN <br />23227015 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />JEFF BURNS <br />Title <br />Day Phone <br />209-551-0120 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0004738 <br />Mail Invoices to Facility <br />Account Name PERKOS CAFE <br />Account Balance as of 7/28/2015: $0.00 <br />1 SSN /Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1626 - RESTAURANT/BAR 101 + SEATS PRO161481 EE0001420 - MELISSA NISSIM 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 Ordinance Codes and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: <br />COMMENTS: <br />* $25.00 = <br />Date <br />Date <br />Amount Paid Date <br />_ Amount Paid Date <br />Received by <br />Account out: Date <br />Invoice #: <br />