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Date run '� 6/26/2015 6:22:43AN SA#AQUIN COUNTY ENV.IRONMENTALI6LTH DEPARTMENT Report#5o21 <br /> Run by Paget <br /> ► Facility Information as of 6/26/2015 <br /> Record Selection Criteria: Facility ID FA0022423 <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 OW0019734 New Owner ID <br /> Owner Name HI PEAK INC <br /> Owner DBA DICKEYS BARBECUE PIT <br /> OwnerAddress 965 GOLDEN POND DR <br /> MANTECA, CA 95336 <br /> Home Phone 209-624-1612 <br /> Work/Business Phone Not Specified <br /> Mailing Address 965 GOLDEN POND DR <br /> MANTECA, CA 95336 <br /> Care of KIWI, KYONG S <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0022423 <br /> Facility Name DICKEYS BARBECUE PIT <br /> Location 15338 S HARLAN RD <br /> LATHROP, CA 95330 <br /> Phone 209-624-1612 <br /> Mailing Address 965 GOLDEN POND DR <br /> MANTECA, CA 95336 <br /> Care of KIM, KYONG S <br /> Location Code 07.- LATHROP Alt Phone <br /> BOS District 003- BESTOLARIDES, STEVE Fax <br /> APN 19611018 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name KIM, KYONG S <br /> Title <br /> Day Phone 209-624-1612 <br /> Night Phone ` <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0041038 NewAccount ID: <br /> Mail Invoices to Owner Mail Invoices to: Owner ! Facility ! Account <br /> Account Name HI PEAK INC (Circle One) <br /> Account Balance as of 612612015: $300.00 <br /> (Circle One) <br /> Transfer to ActiveAnactve <br /> ProgramfElement and Description Record ID Employee ID and Name Status New owner? Defete <br /> 1624-RESTAURANTIBAR 21-50 SEATS PRO539147 EE0001420-MELISSA NISSIM Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: ],the undersigned owner,operator or agent of same,acknowledge that all site,andlor project speck,PHSIEHD 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 andror 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 ! ! <br /> Water System to be TRANSFERED: Amount Paid Date ! 1 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date 1 ! Account out: Date 1 1 <br /> COMMENTS: <br /> Invoice#: <br />