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Date run 3/23/2017 2:46:29PI1 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/2312017 <br /> Record Selection Criteria: Faculty ID FA0014349 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 'I SSN I Fed Tax ID <br /> Owner ID OW0006097 New Owner ID <br /> Owner Name RODRIGUEZ,ARMANDO <br /> Owner DBA FLAKOS TAKOS <br /> OwnerAddress 4020 SAND HARBOUR LN <br /> ELK GROVE, CA 95758 <br /> Home Phone 209-954-8510 <br /> Work/Business Phone 209-625-8515 <br /> Mailing Address 4020 SAND HARBOUR LN <br /> ELK GROVE, CA 95758 <br /> Care of RODRIGUEZ,ARMANDO <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0014349 <br /> Facility Name FLAKOS TAKOS <br /> Location 123 W ELM ST <br /> LODI, CA 95240 <br /> Phone 209-625-8515 <br /> Mailing Address 4020 SAND HARBOUR LN <br /> ELK GROVE, CA 95758 <br /> Care of RODRIGUEZ,ARMANDO <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> T A"PN- 04302415 T � l— — EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name RODRIGUEZ.ARMANDO <br /> Title OWNER <br /> Day Phone 209-954-8510 <br /> Night Phone 209-625-8515 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0024382 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner ! Facility 1 Account <br /> Account Name FLAKOS TAKOS (Circle One) <br /> Account Balance as of 3/23/2017: $0.00 <br /> (Circle One) <br /> Transfer to Active/lnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1624-RESTAURANTIBAR 21-50 SEATS PR0519191 EE0001084-STEPHANIE RAMIREZ Active Y N A I D <br /> 1919-HMBP-0O2 Only Food Facility PR0541649 EE0001084-STEPHANIE RAMIREZ Active Y N A © D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: €,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party ident'rfied as the OWNER on this form_ 1 also certify that all operations will he performed in accordance with all applicable Ordinance Codes and/or Standards and State andlor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I 1 <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 Re ed <br /> EHD Staff: Date I 1 Account out: Date Jc 1 �-� ! <br /> COMMENTS: <br /> 2'�j� j'� �SPaK� � ��"�✓a't01 �j/Ca " �rl7 ' 3 53�� ✓VI Gl✓1Qc jnpice#: <br /> s01 bG5 jr ✓Ids✓ Df C.0,z LI I �2ePdr i"P�'�fi <br /> Ir COZ Bpd.-Jrr�rt� <br /> Prausuol 0 307 <br />