Laserfiche WebLink
Date run 3/16/2016 11:27:31AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 3/16/2016 <br />Record Selection Criteria: Facility ID FA0003077 <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 OW0014511 New Owner ID <br />Owner Name Omar Alrahimee <br />Owner DBA CALIFORNIA FIVE STAR BURGER <br />Owner Address 625 BERK AVE #7 <br />RICHMOND, CA 94804 <br />Home Phone 510-604-8039 <br />Work/Business Phone 510-604-8039 <br />Mailing Address 625 Berk Ave Apt #7 �1 `J /`�qr `e S fl� <br />_ <br />Richmond, CA 94804 1e- <br />C_ A SA t-1 <br />Care of RAHIMEE, OMAR AL <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0003077 10181055 <br />Facility Name FIVE STAR BURGER <br />Location 400 W ELEVENTH ST <br />TRACY, CA 95376 <br />Phone 209-836-6032 x <br />Mailing Address 400 W 11 th Street <br />Tracy, CA 95376 <br />Care of Omar Alrahimee <br />Location Code 03 -TRACY Alt Phone <br />BOS District 005 - ELLIOTT, BOB Fax <br />APN 235 04 011 EMail: <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name RAHIMEE, OMAR AL <br />Title <br />Day Phone 209-835-3308 <br />Night Phone 510-604-8039 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0002640 <br />New Account ID: <br />Mail Invoices to Account Mail Invoices to: <br />Owner / Facility / Account <br />Account Name Omar Alrahimee <br />(Circle One) <br />Account Balance as of 3/16/2016: $290.00 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name <br />Status New Owner? Delete <br />1624 - RESTAURANT/BAR 21-50 SEATS PRO161421 EE0001420 - MELISSA NISSIM <br />Active Y N A I D <br />1921 - HMBP-Regular-Primary Location PR0527144 EE0000010 - PETER LOMBARDI <br />Active Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0534142 <br />Inactiv( 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 3 /�/ <br />Invoice #: <br />Ci�%&XN cy { j OLS F -e J' <br />