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Daterun, � 6}126/2015 1:16:17Pti SAP AQUIN CDUNTV ENVIRONMENTAL F LTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 6/26/2015 Record Selection Criteria: Facility ID FA0022422 Make changestcorrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) OWNER FILE INFORMATION Number of facilities for this owner Owner ID OW0019733 Owner Name MVD RUIZ INC Owner DBA DICKEYS BARBECUE PIT OwnerAddress 2771 AMATCHI CT Phone TRACY, CA 95304 Home Phone 209-879-3920 Work/Business Phone Not Specified Mailing Address 2771 AMATCHI CT Location Code TRACY, CA 95304 Care of RUIZ, VERONICA FACILITY FILE INFORMATION 1 SSN / Fed Tax ID New Owner ID : Facility ID / CERS ID FA0022422 Facility Name DICKEYS BARBECUE PIT Location 2469 NAGLEE RD 4D TRACY, CA, 95304 Phone 209-642-7752 Mailing Address 2469 NAGLEE RD 4D TRACY, CA 95304 Care of RUIZ, VERONICA Location Code 03 -TRACY Alt Phone BOS District 005 - ELLIOTT, BOB Fax _ APN EMail : EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name RUIZ, VERONICA4D Title Day Phone 209-642-7752 Night Phone 209-879-3920 ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0041037 Mail Invoices to Facility Mail Invoices to: Account Name DICKEYS BARBECUE PIT Account Balance as of 6/26/2015: $323.00 New Account ID: : Owner / Facility / Account (Circle One) (Circle One) Transfer to Active/Inactve Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete 1625 - RESTAURANT/BAR 51-100 SEATS PR0539146 EE0001420 - MELISSA NISSIM Active Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andlor project specific, PHS/EHD hourly charges associated with this facility 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 Federal Laws. APPLICANT'S SIGNATURE: Program Records to be TRANSFERED: Water System to be TRANSFERED: Payment Type Check Number EHD Staff: COMMENTS * $25.00 = Date Amount Paid Date _ Amount Paid Date Received by Date / / Account out: Date Invoice #: