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Date. 272011 9:57:10AM SAN JG UIN COUNTY ENVIRONMENTAL HEALTI 3PA,Ii71NENF'y CL9^11 esazr <br /> Run by � � Pape7 <br /> Facility Information as of 2/7/2011 FEB - <br /> lt t 15r nGxanr F elrf N) FAOP18457 <br /> OA <br /> Make chanqes1vorK@T49F N COUNTY <br /> INFORMATION CHAN C� <br /> / Q e5 OWNERSHIP CHANGE(dale) / <br /> �� <br /> Ow'wID OW0012083 r <br /> Owner Name ,r/2ljj�i —.yam � J/1/ <br /> Owner DBA ROUND TABLE PIZZA <br /> Owlrer Address ^ R P <br /> -TA46HlTA,K�-62188- 1 <br /> Home Phone_92&g6y.3qeq- r <br /> Work/ausirwas Phona_4$.5-6&g_3q7g_ <br /> Imaging Address <br /> Wle <br /> 40'i 87 <br /> Care of-t{��p-F� <br /> FACILITY FILE INFORMATION �`� /�R�c ✓ (7�� 19/J7 <br /> Facf6ty lD FA0018457 f v(9Lv <br /> FaciOly Name ROUND TABLE PIZZA �- - <br /> Location 2511 NAGLEE RD <br /> TRACY, CA 95304 <br /> Phone 209-832-0058 - <br /> Melling Address <br /> AnH8 <br /> Care of_GgRpaAW TZRR} <br /> 4i 49 4 - <br /> Location Code 03-TRACY AJ(Phona ' <br /> BOS District 005-ORNELLAS, LEROY Fax <br /> APN 21229037 Email <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name LEGAL DEPT <br /> Title <br /> Day Phone 209-632-0058 <br /> Night Phone 925-969-3900 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ACCOUM ID AR0032607 New <br /> Mail Invoices to Facility Mail involves bt Owner recikty / Account <br /> Account Name ROUNDTABLE PIZZA rcado oml <br /> Account Balance as of 2/712011: $304.00 — i%2,�3 B"T8 <br /> tGba oMl <br /> pMger,rElwnOnl wM 0..W., Rw ID Enlplaw O.M Merril $ T'Omhrb A[INMnatlw <br /> e MYI� <br /> 1825-RESTAURANT/BAR 51-IW SEATS PR0527263 CED001420-MELISSA MENDE Active Y N A I 77- <br /> 2244- <br /> 2244•PACT TRANSFER RECORD-CES PRO530647 Act" Y N A 1 0 <br /> ERSC.ELECTRONIC REPORTING SURCHARGE PRO531451 Active Y N A 1 0 <br /> aILLWG wed COMPUA NCE ACRNOWLEOGEwW I,qe ee e.n,er,egreloror epwn al rw\e,aano.AeENe IMI ep r11a,wM/w INsNtt pw1nG PM$rF�lnury m�giw aseodwee wrh m�e <br /> fedlllr d w.tMq elF W qYe lOtm Wra'Ia01R11100 Af IOn w an ws lann. Isla wlNr ww all apwwMe WA M(rMwmsd h OCCw00nta Wel M Opgloab CneuA Calls wlwor 31erw/ds wttl <br /> Stela"D,Fadwal Lees. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRAN REO- $25.00- Amount Paid pp�gte /_/_ <br /> WBler System to be TRAN�SFERED: Amgmt Paid� Uete 1 /L 1 <br /> Payment Type t/ Charm Number ( 03 S Rem by <br /> REHS: Dale Z 1�,f AtoountlwC DatePAYMEhrr <br /> cowAE <br /> RECENED <br /> FEB -7 ton <br /> \\eh Pnvlenvi RionVetwr1915p21. <br /> not bnV JO/1l7UIP/ <br /> F.NVIROI'1MEtYf,� .� <br />