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Date run ' 8/25/2015 11:07:50AI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 8/25/2015 <br />Record Selection Criteria: Facility ID FA0006597 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0005337 <br />Owner Name <br />GUINTA, FRANK JR <br />Owner DBA <br />CHEZ SHARI <br />Owner Address <br />1892 OLIVEWOOD PL <br />Phone <br />MANTECA, CA 95336 <br />Home Phone <br />Not Specified <br />Work/Business Phone <br />209-518-3794 <br />Mailing Address <br />305 N UNION RD <br />Location Code <br />MANTECA, CA 95337 <br />Care of <br />003 - BESTOLARIDES, STEVE <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0006597 10182127 <br />Facility Name <br />CHEZ SHARI <br />Location <br />305 N UNION RD <br />MANTECA, CA 95337 <br />Phone <br />209-825-8524 x0 <br />Mailing Address <br />305 N UNION RD <br />MANTECA, CA 95337 <br />Care of <br />John Guinta <br />Location Code <br />04 - MANTECA <br />Bos District <br />003 - BESTOLARIDES, STEVE <br />APN <br />20015028 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name FRANK GUINTA JR <br />Title <br />Day Phone 209-825-8524 <br />Night Phone 209-823-7225 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0008872 <br />Mail Invoices to Odyn <br />Account Name G TA, OF FR <br />R <br />Account Balance as of 8/25/20.00 <br />$0.00 <br />Make changestcorrections in RED ink. 1 '� <br />INFORMATION CHANGE (date) 1 <br />OWNERSHI CHHANG!+ <br />E (date) <br />1 SSN / Fed Tax ID / — < <br />Neyv Owner D <br />c 'Se -s n <br />ns NCT <br />Gn CaCA 9s3 -S-7 <br />,Poci F,a T KS2� <br />Vv� <br />Alt Phone <br />Fax <br />EMail: <br />IoyV, 1-- \ /".AG <br />New Account ID: : <br />Mail Invoices to: Owner Facility / Account <br />cle 0 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status wOwner? Delete <br />1626 - RESTAURANT/BAR 101 + SEATS PR0505180 EE0004589 - KADEANNE LINHARES Active N A D <br />1921 - HMBP-Regular-Primary Location PR0536316 EE0002474 - MICHAEL PARISSI Active N A D <br />ERSC - ELECTRONIC REPORTING STATE SURCHARG PR0536300 EE0000000 - HAZ MAT SJC OES Inactive Y N A D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owngr, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility <br />or activity will be billed to the party identified as the DWWYER on this form. I o certify that all operations will be performed in accordance with all applicable Ordinance Codes and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: Dat4 2 S <br />Program Records to be TRAP ED: ' $25.00 = Amount Paid Date <br />Water Syste be TR ERED: Amount Paid Date <br />PaymeW yp Check Number Received by <br />EHD tall: ! Date / n / _? Account out: Date 2/ / /S <br />COMMEXL&/ <br />Invoice # <br />