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Date run 12/2/2010 9:32:18An SAN JI, IUIN COUNTY ENVIRONMENTAL HEI ;H DEPARTMENT Report#5021 <br /> Run by `� �/ Page 1 <br /> Facility Information as of 12/2/2010 <br /> Record Selection Criteria: Facility ID FA0001959 <br /> Make changes/corrections In RED Ink. <br /> F 1 L E INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0006101 New Owner ID : <br /> Owner Name REYNA, GAMALIEL&SABRINA <br /> Owner DBA MEXICO LINDO RESTAURANT <br /> Owner Address 9407 STONY CREEK LN <br /> STOCKTON, CA 95219 <br /> Home Phone 209-952-1205 <br /> Work/Business Phone 709-477-3211 <br /> Mailing Address 9407 SONY CREEK LN <br /> STOCKTON, CA 95219 <br /> Care of GAMALIEL &SABRINA REYNA <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0001959 <br /> Facility Name MEXICO UNDO RESTAURANT <br /> Location 3410 W HAMMER LN STE C <br /> STOCKTON, CA 95219 <br /> Phone 209-477-3211 <br /> Mailing Address 9407 STONY CREEK LN <br /> STOCKTON, CA 95219 <br /> Care of GAMALIEL &SABRINA REYNA <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOIS District 003 - BESTOLARIDES Fax <br /> APN 07120014 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name GAMALIEL&SABRINA REYNA <br /> Title <br /> Day Phone 209-477-3211 <br /> Night Phone 209-952-1205 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0011118 New Account ID <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name MEXICO UNDO RESTAURANT (Circle One) <br /> Account Balance as of 12/2/2010: $0.00 <br /> (Cincte One) <br /> Transferto Active/Inacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 1624-RESTAURANT/BAR 21-50 SEATS PRO162624 EE0000149-RAYMOND BORGES Active Y N A D <br /> BILLING and COMPLIANCE ACKNOVCEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also canary that all operations will be performed in accordance with all applicable Ordinace Codes and/or Standards and <br /> VState end/or Federal Laws. <br /> /� APPLICANT'S SIGNATURE: !'...' '��l�/ Dam �Z 1-70--1-Z-0/ `Program Records to be TRANSFERED: ""$2 .00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type -- —,—Check Number Recall b <br /> RENS: Date Account out: Date Z/_ y {,'(�r-,-� <br /> COMMENTS: <br /> LA. s If,..gSs lyoS,E w�,C 2 �^IO <br /> E,g . <br /> "JH <br /> \\eh-envlenvision\reports\5021.rpt <br /> PEi��ti i(SERVICES <br />