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Date ran 2/20/2014 11:46:51AI SAN JO IN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report 95021 <br /> Run by ` Pagel <br /> + Facility Information as of 2/20/2014 <br /> Record Selection Criteria: Facility 10 FA0018457 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0017022 New Owner ID <br /> Owner Name INTERNATIONAL HOUSE OF TRADE <br /> Owner DBA ROUND TABLE PIZZA <br /> Owner Address 3574 WIND CAVE CT <br /> PLEASANTON, CA 94588 <br /> Home Phone 925-485-4348 <br /> Work/Business Phone 925-548-1975 <br /> Mailing Address 3574 WIND CAVE CT <br /> PLEASANTON, CA 94588 (raSnrt oti 9fS�o(��7D� <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0018457 10,186,869 <br /> Facility Name ROUND TABLE PIZZA <br /> Location 2511 NAGLEE RD <br /> TRACY, CA 95304 <br /> Phone 925-548-1975 xCELL <br /> Mailing Address 3574 WIND CAVE CT <br /> PLEASANTON, CA 94688 P-- yS� �I�9U7 <br /> Care of FARZIN A YAZDY <br /> Location Code 03-TRACY Alt Phone <br /> BOIS District 005 - ELLIOTT, BOB Fax <br /> APN 21229037 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name FARZIN A YAZDY <br /> Title <br /> Day Phone 925-548-1975 Cell <br /> Night Phone 925-485-4348 xHOME <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0032607 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name ROUND TABLE PIZZA (Circle One) <br /> Account Balance as of 2/20/2014: $290.00 <br /> (Circle One) <br /> Transferto Active/InacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO627253 EE0001420-MELISSA NISSIM Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PRO530847 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0531451 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,PHSfEHD 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 ander Standards and State angler <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 Receiv by <br /> REHS: Date I / Account out: Date <br /> COMMENTS: <br />