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Date run 9/6/2018 4:07:41 PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 Run by Pagel Facility Information as of 9/6/2018 Record Selection Criteria: Facility ID FA0002446 OWNER FILE INFORMATION Number of facilities for this owner owner ID OW0001871 Owner Name DELTA RE LLC & DELTA CLP Owner DBA DELTA CASINO BAR RESTAURANT Owner Address 240 N KENTER AVE Status LOS ANGELES, CA 90049 Home Phone 209-817-1025 Work/Business Phone 209-267-4567 Mailing Address 1014 NINTH ST Active SANTA MONICA, CA 90403 Care of MARCARIAN, TIGRAN Z FACILITY FILE INFORMATION Facility ID / CERS ID FA0002446 10180931 Facility Name DELTA CASINO BAR RESTAURANT Location 6518 PACIFIC AVE STOCKTON, CA 95207 Phone 209-948-1100 x Mailing Address 6518 PACIFIC AVE STOCKTON, CA 95207 Care of Delta CLP Location Code 01-STOCKTON Bos District 002 - MILLER, KATHERINE APN 08126047 EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name NADER H TAFTY Title Day Phone 209-948-1100 Night Phone 209-817-1025 Cell ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0004689 Mail Invoices to Account Account Name DELTA CASINO BAR RESTAURANT Account Balance as of 9/6/2018: $-260.00 Program/Element and Description Make changes/corrections in RED ink. INFORMATION CHANGE (date) OWNERSHIP CHANGE (date) SSN / Fed Tax ID New Owner ID : Alt Phone Fax EMail : Record ID Employee ID and Name New Account ID: Mail Invoices to: Owner / 1621 - BAR w/o FOOD PREP PRO160813 EE0003361 - MARIBEL FLOHRSCHUTZ 1919 - HMBP-0O2 Only Food Facility PR0536817 EE0003361 - MARIBEL FLOHRSCHUTZ ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0536848 Facility / Account (Circle One) BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or 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 and/or Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Tye Ch ck Number Received w EHD Staff: ✓Vl • Date / / Account out: Date COMMENTS: Invoice #: (Circle One) Transfer to Active/Inactve Status New Owner? Delete Active Y N A � D Active Y N A D Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or 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 and/or Federal Laws. APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Tye Ch ck Number Received w EHD Staff: ✓Vl • Date / / Account out: Date COMMENTS: Invoice #: