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Date run 11/18/2016 4:19:20F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Paget <br /> Facility Information as of 11/18/2016 <br /> Record Selection Criteria: Facility ID FA0001587 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 3 SSKI Fed Tax ID <br /> Owner ID OW0014521 New Owner ID <br /> Owner Name GK BBQ RESTAURANTS INC <br /> Owner DBA GK MONGOLIAN BBQ <br /> Owner Address 4719 QUAIL LAKES DR G <br /> STOCKTON, CA 95207 <br /> Home Phone 209-221-7008 <br /> WorklBusiness Phone 209-681-1521 <br /> Mailing Address 4719 QUAIL LAKES DR STE G PMB#505 <br /> STOCKTON, CA 95207 <br /> Care of MATT SHIH <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0001587 10180783 <br /> Facility Name GHINGGIS KHAN <br /> Location 2233 GRAND CANAL BLVD STE 117 <br /> STOCKTON, CA 95207 <br /> Phone 209-952-3137 <br /> Mailing Address 4719 QUAIL LAKES DR STE G PMB#505 <br /> STOCKTON, CA 95207 <br /> Care of MATT SHIH <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 11011006 EMall: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SHAO-YEEN OR MATTHEW SHIH <br /> Title <br /> Day Phone 209-952-3137 <br /> Night Phone 209-681-1521 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0001586 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name GHINGGIS KHAN (Circle One) <br /> Account Balance as of 11/18/2016-. $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1626-RESTAURANTIBAR 101 +SEATS PR016D493 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> 1919-HMBP-0O2 Only Food Facility PRO528755 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A (nI )D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533421 Inactiv( Y N A I D <br /> BELLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that ail site,and+or project specific.PHSVEHD 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 applicabie Ordinance Codes and/or Standards and State andlor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date I 1 <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date I / <br /> Water System to be TRANSFERED: Amount Paid Date I ! <br /> Payment Type Check Number Received r <br /> EHD Staff: Date jLAccount out: Date 11 <br /> COMMENTS: L Le <br /> ,, _ 'J fes, <br /> G�-k k-� � l e ��'wt n 1 61 t.YJ O '' �1 Invoice#: <br />