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Date mn 2/28/2006 11:59:19AN SAN JO AN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report#5021 <br /> Pagel <br /> Run by 4006 _ ility Information as of 2/28/2006 <br /> s <br /> Record Selection Criteria reality ID FA0001959 r. <br /> ..Y Make changes/corrections 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 REYNA, GAMALIEL & SABRINA <br /> Owner DBA MEXICO UNDO 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 LINDO 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 APN 07120014 <br /> BOS District 002 - MARENCO, DARIO SIC Code. <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 LINDO RESTAURANT (Cnd.Do.) <br /> Account Balance as of 2/28/2006: $240 00 <br /> (Gird.One) <br /> Transfer to g velraMe <br /> Aog emanl and Desmption Record ID Employee ID and Name Status New Owner' Delete <br /> )015-RESTAURANT/BAR 51-100 SEATS PRO162624 EE0003361 -MARIBEL FLOHRSCHUTActive Y N A I D <br /> BILLING end COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operates or agent of same,ac nmMedge that all site,andlor proled specific.PHS/EHD howdy charges associated with Nis <br /> fatllity or activitywill be billed to the party idenfified as the OWNER on this form. I also oaditythat all operations will beperformed in a dancewith all applicable Ordinate Codes and/orStandardsaid <br /> Stale and/er Federal Lars. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date <br /> Payment Type Check Number Received by ^ / <br /> RENS: YUA: L L- Date 3 !�/ O f� Account out: Zri Date <br /> COMMENTS: <br /> \\ph s-ehsgl-nt\apps\envisions\reports\5021.rpt <br />