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Dale win 1/13/201610:10:07AP SAN JO IN COUNTY ENVIRONMENTAL HEAL#EPARTMENT Report#5021 <br /> Run by !� Pagel <br /> Facility Information as of 1!13/2016 <br /> Record Selection Criteria: Facility ID FA0002230 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: t SSN/Fed Tax ID <br /> Owner ID OW0001728 New Owner ID <br /> Owner Name Nakashima, Ren <br /> Owner DBA PACIFIC AVENUE BOWL <br /> OwnerAddress 5939 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-649-0369 <br /> Mailing Address 5939 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0002230 10180891 <br /> Facility Name PACIFIC AVENUE LOUNGE <br /> Location 5939 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Phone 209-477-0267 x0 <br /> Mailing Address 5939 PACIFICAVE <br /> STOCKTON, CA 95207 <br /> Care of Pacific Avenue Lounge/Alan Taylor <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 10812030 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name PACIFICAVENUE LOUNGE <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002242 NewAccount ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name PACIFIC AVENUE LOUNGE (Circle One) <br /> Account Balance as of 1/13/2016: $0.00 <br /> (Circle One) <br /> Transferto Activellnaclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1621 -BAR w/o FOOD PREP PRO160062 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> 1921 -HMBP-Reqular-Primary Location PRO520854 EE0000006-HAZA SAEED Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PR0515835 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PRO515836 EE0001699-JOHNNY YOAKUM Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGE PRO531697 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT I,Me undersigned owner,operator or agent of same,acknowledge that all site,ander project speck,PHS/EHD hourly charges associated with this facility or <br /> 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 ardor Standards and State ani 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 / / Account out: Date / / <br /> COMMENTS: <br /> Invoice#: <br />