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Date run 12/23/2015 2:24:41P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/23/2015 <br /> Record Selection Criteria: Facility ID FA0003268 <br /> Make changes/corrections in RED ink. `� r� <br /> INFORMATION CHANGE(date) Gt'-fC3J15 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID : <br /> Owner ID OW0006616 New Owner ID <br /> Owner Name GA INTERNATIONAL INC <br /> Owner DBA STRAW HAT PIZZA <br /> Owner Address 1350 KNOLLS CREEK DR <br /> DANVILLE, CA 94506 <br /> Home Phone 925-212-3478 <br /> Work/Business Phone Not Specified <br /> Mailing Address 1350 KNOLLS CREEK DR <br /> DANVILLE, CA 94506 <br /> Care of SINGH, GAGAN <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0003268 10646044 <br /> Facility Name STRAW HAT PIZZA <br /> Location 3228 TRACY BLVD <br /> TRACY, CA 95376 <br /> Phone 209-830-7777 <br /> Mailing Address 3228 TRACY BLVD <br /> TRACY, CA 95376 <br /> care of SINGH, GAGAN <br /> Location Code 03 -TRACY Alt Phone <br /> BOS District 005- ELLIOTT, BOB Fax <br /> APN 21445005 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SINGH, GAGAN <br /> Title <br /> Day Phone 209-830-7777 <br /> Night Phone 925-212-3478 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002840 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name STRAW HAT PIZZA (Circle One) <br /> Account Balance as of 12/23/2015: $280.50 <br /> (Circle One) <br /> Transferto Activerinacive <br /> Program'Element and Description Record ID Employee ID and Name Status Naw Owner? Delete <br /> 1626-RESTAURANT/BAR 101 +SEATS PRO161139 EE0001420-MELISSA NISSIM Active Y N AD <br /> 1921 -HMBP-Regular-Primary Location PRO540411 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,andfor 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 l also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andfor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date / I <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Ty heck bar Received by <br /> EHD Sta Date _/ �-3 / �:5 Account out: 4 Date / / ;5!' I Js <br /> COMMENTS: Invoice* <br /> 1&lvwxts &,)L-l- CO2- <br />