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Date rum 6/19/2015 10:40:31AI SAN ,AQUIN COUNTY ENVIRONMENTAL H TH DEPARTMENT Report#5021 <br /> Run by \ \r Pagel <br /> Facility Information as of 6/19/x2015 <br /> Record Selection Criteria: Facility ID FA0001180 <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 OW0000913 New Owner ID <br /> Owner Name WIENERSCHNITZEL <br /> Owner DBA WIENERSCHNITZEL#362 <br /> OwnerAddress 1107 W MARCH LN <br /> STOCKTON, CA 95207 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-931-1044 <br /> Mailing Address 1107 W MARCH LN <br /> STOCKTON, CA 95207 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0001180 10180723 <br /> Facility Name WIENERSCHNITZEL#362 <br /> Location 1107 W MARCH LN <br /> STOCKTON, CA 95207 <br /> Phone 209-473-1686 <br /> Mailing Address 1107 W MARCH LN <br /> STOCKTON, CA 95207 <br /> Care of <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOIS District 002 - MILLER, KATHERINE Fax <br /> APN 10816010 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name FAROUK DIAB <br /> Title <br /> Day Phone 209-473-1686 <br /> Night Phone 209-474-9578 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0001177 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name WIENERSCHNITZEL#362 (Circle One) <br /> Account Balance as of 6/19/2015: $0.00 <br /> (Circle One) <br /> Trariferto Activernadm <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO160127 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0520878 EE0000006-HAZA SAEED Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO515833 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO515834 EE0001699-JOHNNY YOAKUM Inactive Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO533422 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 protect 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 andor 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 /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: <br /> Invoice* <br />