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Datemn ' 9/3/2013 4:16:54PM SAN JO�JIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by Facility Information '7 <br /> r <br /> Record Selection Criteria'. Facility ID FA0018527 <br /> t-e*+ S(a r►�ss�r�e <br /> 4fg ga 411gll3 <br /> OWNER FILE INFORMATION 1 <br /> Owner ID OW0011043 1 A <br /> Owner Name BON APPETIT MGMT CO / rl�a j q (/� law 13 — <br /> Owner DBA — <br /> Owner Address 100 HAMILTON AVE STE 400 �� ✓✓t (' t1b — <br /> PALO ALTO, CA 94301 — <br /> Home Phone 650-798-8000 lqo 'PYLS — <br /> Work/Business Phone 209-460-3890CA- qS 2 1 — <br /> Mailing Address 100 HAMILTON AVE STE 400 5� oHXn7aldPr� <br /> PALO ALTO, CA 94301 LI 54p 1� — <br /> Care of SIA MOHSENZADEGAN GLf+ — <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0018527 <br /> Facility Name DAVEY CAFE <br /> Location 3601 PACIFIC AVE <br /> STOCKTON, CA 95211 <br /> Phone 209-946-2264 c7 <br /> Mailing Address HSE <br /> STOCKTON, CA 95211 <br /> Careof SIA MOHS ENZAD EGAN <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 11314009 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SIA MOHSENZADEGAN <br /> Title <br /> Day Phone 209.948 2264 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0032773 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility I Account <br /> Account Name DAVEY CAFE (Circle One) <br /> Account Balance as of 9/3/2013: $300.00 <br /> (Circle One) <br /> Transfer to Activaiinactve <br /> PrograetlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1623-RESTAURANT/BAR 1-20 SEATS PRO527366 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> 1634-FOOD VEHICLE/CART(PREPKGD ONLY) PRO527367 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT'. I,the undersigned owner,operator or agent of same,aclmowledge that all site,andor project specific,PHS/EHD hourly charges associated with this facility <br /> 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 andor Standards and State ardor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Race <br /> REHS: Date / / Account out: Date 7 / /3 <br /> COMMENTS: <br /> r1/,1e,&&,e—AJLi« <br /> Se--r— Aioo� <br />