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Date run 7/6/2015 8:42:58AM SAN JOAQUV-rCOUIVTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 7/6/2015 Record Selection Criteria: Facility ID FA0018524 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0015217 Owner Name 4 U SMC INC Owner DBA OwnerAddress 1230 EDGEWOOD DR LODI, CA 95240 Home Phone 209-603-7254 Work/Business Phone 209-333-7889 Mailing Address 1230 EDGEWOOD DR LODI, CA 95240 Care of COCKRUM, ROD FACILITY FILE INFORMATION Facility ID / CERS ID FA0018524 Facility Name DICKEYS BARBECUE PIT Location 1446 HULSEY WAY MANTECA, CA 95336 Phone 209-239-2333 Mailing Address 1230 EDGEWOOD DR LODI, CA 95240 Care of COCKRUM, ROD Location Code 04 - MANTECA Bos District 005 - ELLIOTT, BOB APN 22120058 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name COCKRUM, ROD Title Day Phone 209-239-2333 Night Phone 209-603-7254 ACCOUNTS RECEIVABLE FILE INFORMATION Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) 2 SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail : Account ID AR0032761 Mail Invoices to Facility Mail Invoices to: Account Name DICKEYS BARBECUE PIT Account Balance as of 7/6/2015: $0.00 New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Activelinactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1624 - RESTAURANT/BAR 21-50 SEATS PR0527363 EE0004589 - KADEANNE LINHARES Active Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility 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 and/or Standards and State anclor Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS: Date " $25.00 = Amount Paid Date Amount Paid Date Received by Account out: Date Date Invoice #: