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Date run 7/1/2018 9:16:31AM SAN JO IN COUNTY ENVIRONMENTAL HEA DEPARTMENT <br /> Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/1/2015 <br /> Record Selection Criteria: Facility ID FA0022408 <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 OW0019662 New Owner ID <br /> Owner Name SULIMAN, WASSIM <br /> Owner DBA WIENERSCHNITZEL MH #827 <br /> OwnerAddress 557 W VIENTO ST <br /> MOUNTAIN HOUSE, CA 95391 <br /> Home Phone 530-409-8127 <br /> Work/Business Phone Not Specified <br /> Mailing Address 25432 S SCHULTE RD <br /> TRACY, CA 95377 <br /> Care of SULIMAN, WASSIM <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0022408 <br /> Facility Name WIENERSCHNITZEL MH#827 <br /> Location 25432 S SCHULTE RD <br /> TRACY, CA 95377 <br /> Phone 530-409-8127 <br /> Mailing Address 25432 S SCHULTE RD <br /> TRACY, CA 95377 <br /> Care of SULIMAN, WASSIM <br /> Location Code Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SULIMAN, WASSIM <br /> Title <br /> Day Phone 530-409-8127 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0041022 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name WIENERSCHNITZEL MH #827 (Circle one) <br /> Account Balance as of 71112015: $545.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1623-RESTAURANTIBAR 1-20 SEATS PRO539115 EE0001420-MELISSA NISSIM Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PRO540250 EE0000010-PETER LOMBARDI Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHSIEHD 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 and/or Standards and State andor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date ! 1 <br /> Program Records to be TRANSFERED: `$25.00= Amount Paid Date ! 1 <br /> Water System to be TRANSFERED: Amount Paid Date ! 1 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date 1 1 Account out: Date I ! <br /> COMMENTS: Invoice#: <br />