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Date run 5/15/2015 9:26:12Ah SAN J*IN COUNTY ENVIRONMENTAL HEAW DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 5/15/2015 <br /> Record Selection Criteria: Facility ID FA0019105 <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 OW0015717 New Owner ID <br /> Owner Name BOUDIN SF <br /> Owner DBA BOUDIN SF <br /> Owner Address 221 MAIN ST 1230 <br /> SAN FRANCISCO, CA 94105 <br /> Home Phone 415-477-8200 <br /> Work/Business Phone 415-287-1700 <br /> Mailing Address 221 MAIN ST STE 1230 <br /> SAN FRANCISCO, CA 94105 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0019105 10187057 <br /> Facility Name BOUDIN SF <br /> Location 5615 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Phone 209-952-2000 x <br /> Mailing Address 5615 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Care of BOUDIN SF <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 10813022 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name BOUDIN SF <br /> Title <br /> Day Phone 209-952-2000 <br /> Night Phone 415-477-8200 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0034025 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name BOUDIN SF (Circle One) <br /> Account Balance as of 5/15/2015: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inacive <br /> ProgranvElement and Description Record ID Employee ID and Name Status New Oman Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO628265 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0629928 EE0000006-HAZA SAEED Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO532560 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 project specific,PHSrEHD 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 and" <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_I / Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />