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4 <br /> Date run 2/24/2017 3:46:011"'A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Pagel <br /> Facility Information as of 2/24/2017 <br /> Record Selection Criteria: Facility ID FA0019105 <br /> I <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) l <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN I 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 ID!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 /> ;1 <br /> Mailing Address 221 Main St. Ste 1230 <br /> SAN FRANCISCO, CA 94105 <br /> Care of BOudin SF <br /> Location Code 01 - STOCKTON Aft Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 10813022 EMail: <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 Account Mail Invoices to: Owner / Facility ! Account <br /> Account Name BOUDIN SF (Circle one) <br /> Account Balance as of 212412017; $329.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramfFlement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PR0528265 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> 1919-HMBP-0O2 Only Food Facility PR0529928 EE0006213-VIDAL PEDRAZA Active Y N A 0 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532560 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor 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 andlor Standards and State ancilor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 ! <br /> Payment Type Check Number Receive <br /> EHD Staff:__ _ 1 �V Date 2- 1 211 1 I Account out: Date !��117 <br /> COMMENTS: t <br /> Invoice#: <br /> T70 Gl <br />