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Date run 11/29/2017 4:51:52F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 11/29/2017 Record Selection Criteria: Facility ID FA0002035 OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0000819 Owner Name Anil Yadav Owner DBA 2670 W March Ln Owner Address 3550 MOWRY AVE 301 Phone FREMONT, CA 94538 Home Phone 510-792-3393 Work/Business Phone 510-792-3393 Mailing Address 2670 W March Ln Location Code Fremont, CA 94538 Care of 002 - MILLER, KATHERINE FACILITY FILE INFORMATION Facility ID / CERS ID FA0002035 10738816 Facility Name Dennys Location 2670 W March Ln Stockton, CA 95207 Phone 209-743-3063 x Mailing Address 2670 W March Ln Stockton, CA 95207 Care of Dennys Location Code 01 - STOCKTON BOS District 002 - MILLER, KATHERINE APN EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name CENTRAL VALLEY DINER INC Title Day Phone 209-478-1633 Night Phone 510-792-3393 ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0002043 Mail Invoices to Account Account Name Gustavo Munoz Account Balance as of 11/29/2017: $255.60 Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) 18 SSN / Fed Tax ID New Owner ID : 3550 m oax q e- -�+ 3,Dl r12'm n I- , q 4S 3 i;�' Alt Phone Fax EMail : Mail Invoices to: New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1626 - RESTAURANT/BAR 101 + SEATS PRO160489 EE0003361 - MARIBEL FLOHRSCHUTZ Active Y N A I D 1919 - HMBP-0O2 Only Food Facility PR0541785 EE0003361 - MARIBEL FLOHRSCHUTZ Active Y N A I D 2066 - MILK DISPENSER PR0200205 EE0000370 - WILLIAM MARCHESE Inactive 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 ancl/or Standards and State andfor Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: Date $25.00 = Amount Paid Date Amount Paid Date Received b '7 _ Date / / Account out: I Date / / COMMENTS: Invoice #: