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Date run 5/28/2015 9:14:39AA SAN JOWUIN COUNTY ENVIRONMENTAL HEAW DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 5/28/2015 <br /> Record Selection Criteria: Facility I D FAD016285 <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 OW0013172 New Owner ID <br /> Owner Name PINNACLE RESTAURANT LP _ <br /> Owner DBA GOLDEN CORRAL BUFFET & GRILL <br /> Owner Address PO BOX 641041 <br /> SAN FRANCISCO, CA 94164 <br /> Home Phone 415-828-9327 <br /> Work/Business Phone 415-674-7919 <br /> Mailing Address PO BOX 641041 <br /> SAN FRANCISCO, CA 94164 <br /> Care of ROBERT GOODWIN, PARTNER <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0016285 10185143 <br /> Facility Name GOLDEN CORRAL BUFFET& GRILL <br /> Location 2850 W GRANT LINE RD <br /> TRACY, CA 95304 <br /> Phone 209-834-1420 x <br /> Mailing Address 2850 W GRANT LINE RD <br /> TRACY, CA 95304 <br /> Care of PINNACLE RESTAURANT <br /> Location Code 03 -TRACY Alt Phone <br /> Bos District 005- ELLIOTT, BOB Fax <br /> APN 23860021 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name PINNACLE RESTAURANT <br /> Title <br /> Day Phone 209-834-1420 <br /> Night Phone 415-828_9327 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0028488 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 'Facility 1 Account <br /> Account Name GOLDEN CORRAL BUFFET& GRILL (Circle One) <br /> Account Balance as of 5/28/2015-. $347.00 <br /> (Circle One) <br /> Transfer to Activellratove <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1626-RESTAURANT/BAR 101 +SEATS PR0524273 EE0001420-MELISSA NISSIM Active Y N A I D <br /> 1921 -HMBP-Reqular-Primary Location PR0526523 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0534236 InactivE 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,PHSfEHD 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 andlor Standards and State andror <br /> Federal Laws, <br /> APPLICANT'S SIGNATURE: Date -1-1 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 / <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date 1 i Account out: Date 1 1 <br /> COMMENTS: Invoice#: <br />