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Date run 711/2014 2:40:58PM SAN JO 'JIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report#5921 <br /> .,., Pagel <br /> Run by Facility Information as of 7/1/2014 <br /> Record Selection Criteria: Facility ID FA00061 14 <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 OW0005205 New Owner ID <br /> Owner Name GOMEZ, MARGARITO <br /> Owner DBA <br /> Owner Address 19450 HIDDEN LAKES <br /> ACAMPO, CA 95220 <br /> Home Phone 209-333-1759 <br /> Work/Business Phone 209-333-1759 <br /> Mailing Address P.O. Box 540 <br /> Lockeford, CA 95237 <br /> Care of GOMEZ, MARGARITO <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0006114 10182019 <br /> Facility Name COYOTES MEXICAN DINING <br /> Location 14015 E HWY 88 <br /> LOCKEFORD, CA 95237 <br /> Phone 209-727-5900 x <br /> Mailing Address PO BOX 540 <br /> LOCKEFORD, CA 95237-0540 <br /> Care of COYOTES MEXICAN DINING <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 004 -VOGEL, KEN Fax <br /> APN 01908012 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name GOMEZ, MARGARITO <br /> Title <br /> Day Phone 209-727-5900 <br /> Night Phone 209-333-1759 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0008564 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name COYOTES MEXICAN DINING (Circle One) <br /> Account Balance as of 71112014: $0.00 <br /> (Circle one) <br /> Transfer to Activellnaetve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1623-RESTAURANT/BAR 1-20 SEATS PR05D4197 EE0001084-STEPHANIE RAMIREZ Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0527141 EE0008709-JAMIE DE LA ROSA Active Y N A 1 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534199 Inactive Y N A -1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same..acknowledge that all site,andor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this farm. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ardor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! ! <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED. Amount Paid Date 1 ! <br /> Paymenta�. p,,et Check Number Re <br /> cell.6 <br /> RENS: c .lSJ4 �) Date _l� 1� Account out: --' parte <br /> COMMENT S!' `tiiCJ.J ' r`r' V'i"^� ��( 11�� lSa4i) ! o uG+ 6' -ext p <br />