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Report#5021 <br /> DatclNn /11/2005 11:27:12AI SAN JO. JIN COUNTY ENVIIONMENTAIL HEAL" DEPARTMENT Pagel <br /> Run by Facility Information as of 1/11/2005 <br /> Record Selection Criteria: Facility 10 FA0001959 <br /> Make changeslcorrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0006101 New Owner ID <br /> Owner Name ROBLES, MELECIO & ESTHER <br /> ANAL E SnbRtun ZcY/ A <br /> Owner DBA <br /> Owner Address 731 S MERCED AVE <br /> STOCKTON, CA 95203 5(occzoN CA `t Szt <br /> Home Phone 209-467-3269 (-70') <br /> l �l5 z - l Z o.S <br /> O`� <br /> Work/Business Phone 209-477-3211 7 41 T 2\t <br /> Mailing Address 731 SMERCEDAVE of t0I Scow c\tert �N <br /> STOCKTON, CA 95203 U R SZ r ct <br /> Care of ROBLES, MELECIO & ESTHER Rrc�l# n (DANA S ��<1uti <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0001959 <br /> Facility Name MEXICO LINDO RESTAURANT <br /> Location 3410 W HAMMER LN C <br /> STOCKTON, CA 95219 <br /> Phone 209-477-3211 <br /> Mailing Address 3410 W HAMMER LN STE C <br /> STOCKTON, CA 95219 <br /> Care of ROBLES. MELECIO & ESTHER C nu r t F� S i bt uA RcYNa <br /> Location Code 01 -STOCKTON APN 07120014 <br /> BOS District 002 - MARENCO, DARIO SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> AccountlD AR0011118 New Acc <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name MEXICO UNDO RESTAURANT (Circle One) <br /> Account Balance as of 1/11/2005: $0.00 , �. 01,;777P? <br /> (Circe One) <br /> Transfer to AGivellnadve <br /> New Omer? Delete <br /> ProgramlElementond Description Record ID Employee ID and Name Status <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO162624 EE0003361 -MARIBEL FLOHRSCHU-Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific.PHSIEHD hourly charges associated whh this <br /> facility or activity will be billed to the party idenlRed as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinace Codes and/or standards and <br /> Slate and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: rG Date 1 / I 1 / Zc7O✓f <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: _*$155.00= Amount Paid g6aY� Date <br /> � <br /> Payment Type Check Number 4O V Lt Received by <br /> REHS: CMi Q32-/ _ Date Account out: 1 Date <br /> COMMENTS: <br /> JAN 112005 <br /> SP•ENVIJOIRONMEN a- <br /> HEALTH DEPARTMENT <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />