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Date run f 2/28/2013 9:59:06AR SAN JO/:';K IN COUNTY ENVIRONMENTAL HEA[>g:�;?l Pagel <br /> DEPARTMENT Report*5021 <br /> Run by <br /> Facility Information as of 2/28/2( <br /> Record Selection Criteria: Facility ID FA0000480 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(dat ' - <br /> OWNERSHIP CHANGE(date b� <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0000396 NewOwner r? <br /> Owner Name BENIGNO, BEVERLY <br /> Owner DBA ROCKY'SRESTAURANT <br /> Owner Address 14659 N THORNTON RD <br /> LODI, CA 95242 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified I <br /> Mailing Address PO BOX 2601 <br /> LODI, CA 952 41 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000480 <br /> Facility Name ROOKYSRES TAURANT <br /> Location 14659 N THOf NTON RD <br /> LODI, CA 952* <br /> Phone 209-369-1973 x0 <br /> Mailing Address PO BOX 2601 <br /> LODI, CA 95241 <br /> Care of <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 05515025 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> j Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMA ION <br /> Account ID ARD000479 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name ROCKYS REIE TAURANT (Circle One) <br /> Account Balance as of 2/28/2013: a gd r -- <br /> . (circle One) <br /> Transfer to AdiveAnacNe <br /> ProgreMElement and Description Record ID Employee to and Name Status New Owner? Delete <br /> 1626-RESTAURANT/BAR 101 +SEATS PRO160165 EE0005362-NICHOLAS WIESEMAN Active Y N A I D <br /> i 1920-HMBP-Common Materials PRO521616 EE0008709-JAMIE DE LA ROSA Active Y N A t) D <br /> y ERSC-ELECTRONIC REPORTING STATE SUR KPR0533581 Inactive Y N A I D <br /> j 4633-TNC WATER SYSTEM WA0461247 EE0005838-ADRIENNE ELLSAESSEInactive Y N A I D <br /> 3 BILLING and COMPLIANCE ACKNOWLEDGEMENT. I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will bs billed to the party identified as the OWNER on this form 1 also certify Mat all operations will be performed in accordance with all applicable Ordinance Codes anddor Standards and State and" <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> S Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Receiv <br /> Date <br /> _RENS` Date / /�j_ Account out: <br /> J�M�c�Ts: i <br />