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Date run 8/31/2015 2:36:57Ph SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 8131/2015 <br /> Record Selection Criteria: Facility ID FA0003268 <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 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 ID/CERS ID FA0003268 <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 /> SOS District 005- ELLIOTT, BOB Fax <br /> APN 21445005 Entail: <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 8/31/2015: $0.00 <br /> (Circle one) <br /> Transfer to Active/InacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1626-RESTAURANT/BAR 101 +SEATS PRO161139 EE0001420-MELISSA NISSIM Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersignetl owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identifietl as the OWNER on this form I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> 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: Invoice* <br />