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Date run 6/13/2017 4:25:18PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by <br />Facility Information as of 6/13/2017 Pagel <br />Record Selection Criteria: Facility ID FA0017990 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID <br />OW0014780 <br />Owner Name <br />BIG LEAGUE DREAMS MANTECA LLC <br />Owner DBA <br />OwnerAddress <br />1077 MILO CANDINI DR <br />MANTECA, CA 95337 <br />Home Phone <br />209-824-2400 <br />Work/Business Phone <br />209-824-2400 <br />Mailing Address <br />1077 MILO CANDINI DR <br />MANTECA, CA 95337 <br />Care of <br />COOKSON, CHRIS <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0017990 1018674 <br />Facility Name <br />BIG LEAGUE DREAMS SP TS PARK <br />Location <br />1077 MILO CANDINI DR <br />MANTECA, CA 95337 <br />Phone <br />209-824-2400 x <br />Mailing Address <br />1077 MILO CANDIN <br />(Circle One) <br />MANTECA, CA 95 <br />Care of <br />Roy Fetherolf <br />Location Code <br />04 - MANTECA <br />/ <br />Bos District <br />005 - ELLIOTT, B <br />APN <br />24131048 <br />EMERGENCY NOTIFICATION CONTACT INFOR <br />Contact Name COOKSON, CHRI <br />Title <br />Day Phone 209-824-2400 <br />Night Phone <br />ACCOUNTS RECEIVABLE FILE INFORMATION <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 />Alt <br />Account ID AR0031578 <br />New Account ID: <br />: <br />Mail Invoices to Account <br />Mail Invoices to: <br />Owner / <br />Facility / <br />Account <br />Account Name BIG LEAGUE DREAMS <br />SPORTS <br />PARK <br />(Circle One) <br />Account Balance as of 6/13/2017: $0.00 <br />(Circle One) <br />Transfer to <br />Active/Inactve <br />Program/Element and Description <br />Record ID <br />Employee ID and Name <br />Status <br />New Owner? <br />Delete <br />1626 - RESTAURANT/BAR 101 + SEATS <br />PR0526576 <br />EE0004589 - KADEANNE LINHARES <br />Active <br />Y N <br />A <br />I D <br />1626 - RESTAURANT/BAR 101 + SEATS <br />PR0526577 <br />EE0004589 - KADEANNE LINHARES <br />Active <br />Y N <br />A <br />I D <br />1919 - HMBP-0O2 Only Food Facility <br />PR0529211 <br />EE0004589 - KADEANNE LINHARES <br />Active <br />Y N <br />A <br />I D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARGI <br />PR0532196 <br />Inactive <br />Y N <br />A <br />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 />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 b LL/ <br />EHD Staff,,,Az�� A,'No..pz Date 'O Account out: Date / 7 / Z <br />COMMENTS' <br />Invoice #: <br />�� A� \ cl 2 l <br />