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---I <br />Date run 4/19/2016 9:54:16AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 4/19/2016 <br />Record Selection Criteria: Facility ID FA0007134 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID <br />OW0011235 <br />Owner Name <br />CATALINA RESTAURANT GROUP <br />Owner DBA <br />COCO'S #5021 <br />Owner Address <br />5780 FLEET ST 250 <br />Phone <br />CARLSBAD, CA 92008 <br />Home Phone <br />760-476-5146 <br />Work/Business Phone <br />760-476-5146 <br />Mailing Address2-2-� <br />�ay venue, <br />Location Code <br />CARL- - --- 08 <br />Care of <br />004 - WINN, CHARLES <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0007134 10182203 <br />Facility Name <br />COCOS #5021 <br />Location <br />2347 W KETTLEMAN LN <br />LODI, CA 95242 <br />Phone <br />209-339-1227 x <br />Mailing Address <br />2210-F-ARA460,Y-.V1= ST -E-250 <br />CARL-SBAD-CPF92008-7234 <br />Care of <br />LICENSING/PERMITS <br />Location Code <br />02 - LODI <br />Bos District <br />004 - WINN, CHARLES <br />APN <br />02741012 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />GENERAL MANAGER <br />Title <br />Day Phone <br />209-339-1227 <br />Night Phone <br />760-476-5146 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0010334 <br />Mail Invoices to Facility <br />Account Name COCOS #5021 <br />Account Balance as of 4/19/2016: $792.50 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />,moo C.k C' C <br />l-� 01 0 n'A V C' rlC <br />I <br />Alt Phone <br />Fax <br />EMail : <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Desc pt on Record ID Employee ID and Name Status New Owner? Delete <br />1626 - RESTAURANT/BAR 101 + SEATS PRO505996 EE0001084 - STEPHANIE RAMIREZ Active Y N A I D <br />1921 - HMBP-Regular-Primary Location PR0535248 EE0008709 - JAMIE DE LA ROSA Active Y N A I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0535285 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, 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 be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: <br />COMMENTS: <br />Date / !. <br />$25.00 = Amount Paid Date <br />Amount Paid Date <br />Received by <br />Date / / Account out: Z>!!� Date /1� /- <br />Invoice #: <br />