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Date run 1/9/2015 8:39:56AM SAN JOIN COUNTY ENVIRONMENTAL HEA# DEPARTMENT Report#5021 <br /> Pagel <br /> Run W <br /> Facility Information as of 1/9/2015 <br /> Record Selection Criteria: Facility ID FA0001848 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN(Fed Tax ID <br /> OwnerlD OW0001446 New Owner ID <br /> Owner Name CALDER, DAVID <br /> Owner DBA DAVID'S PIZZA INC <br /> Owner Address 10309 HADDONFIELD LN <br /> STOCKTON, CA 952197276 <br /> Home Phone o�-47s C2';' <br /> Work/Business Phone 209-483-6927 <br /> Mailing Address 10309 HADDONFIELD LN <br /> STOCKTON, CA 952197276 <br /> Care of CALDER, DAVID <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0001848 10180815 <br /> Facility Name DAVIDS NEW YORK STYLE PIZZA <br /> Location 1744 W HAMMER LN <br /> STOCKTON, CA 95209 <br /> Phone 209-477-2677 <br /> Mailing Address 1744 W HAMMER LN <br /> STOCKTON, CA 95209 <br /> Care of <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 002 - RLIHSTALLER, LARRY Fax <br /> APN 07728031 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name DAVID CALDER <br /> Title <br /> Day Phone.-298.957-t&" <br /> Night Phone 209-477-2677 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0001852 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name DAVIDS NEW YORK STYLE PIZZA (Circle One) <br /> Account Balance as of 1/9/2015: $0.00 (Circle One) <br /> Transferto Active/Inaclve <br /> ProgreMElemenl and Description <br /> Record ID Employee ID and Name Status New Owner? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PR0160058 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0520649 EE0000006-HAZA SAEED Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513360 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0511072 EE0000000-HAZ MAT SJC OES Inactive: Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533240 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor 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 b,performed in accordance with all applicable Ordinance Codes and/or Standards and State andor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <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 Received by <br /> REHS: Date_/_/_ Account out: Date <br /> COMMENTS: <br />