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Date run 7/30/2008 3:39:58PN SAN JOA`iUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Pagel <br /> Run by Facility Information as of 7/30/20b. <br /> Record Selection CnIbria- Facility ID FA0018527 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0011043 New Owner ID <br /> Owner Name BON APPETIT MGMT CO <br /> Owner DBA <br /> Owner Address 100 HAMILTON AVE STE 300 <br /> PALO ALTO, CA 94301 <br /> Home Phone 650-798-8000 <br /> Work/Business Phone Not Specified <br /> Mailing Address 100 HAMILTON AVE <br /> PALO ALTO, CA 94301 <br /> Care of ~"�+ <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0018527 <br /> Facility Name DAVEY CAFE <br /> Location 3601 PACIFIC AVE <br /> STOCKTON, CA 95211 <br /> Phone 209-946-2264 <br /> Mailing Address 3601 PACIFIC AVE <br /> STOCKTON, CA 95211 <br /> Care of Z (�n <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 ZADEGAN, SIA MOHSEN <br /> Title <br /> Day Phone 209-946-2264 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0032773 New Account ID: <br /> Mail Invoices to Facility /1 Mail Invoices to: Owner / Facility / Account <br /> Account Name DAVEY CAFE (J�( -^�tp (Circle One) <br /> Account Balance as of 7/30/2008: $220.00 Lame (Circle One)Transfer to Activennactve <br /> mProgramlElement and Description Remployee ID and Status New Owner? Delete <br /> 1623-RESTAURANT/BAR 1-20 SEATS PR0527366 EE0003474-CHANDRA VEGA Active Y N A I D <br /> 1634-FOOD VEHICLE/CART(PREPKGD ONLY) PRO527367 EE0000149-RAYMOND BO 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 pmlect specific,PHS/EHD hourly charges associated with this <br /> facility or activity will be filled to the party identified 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 /> State and/or Federal Laws. 11 'o^'_'�'\}t p <br /> APPLICANT'S SIGNATURE: S C- C- \rjf -o •\ Y�l�`u'r'�" `1`WU 0. a Date �/aU <br /> Program Records to be TRANSFERED: '$20.00= Amount Paid Date / I <br /> Water System to be TRANSFERED: _*$372.00= Amount Paid Date <br /> Payment Type Check Number Re,e�ce((iiv7veed�d by <br /> REHS: Date / / Account out: yyL� Date / <br /> COMMENTS: ^ - <br /> \\phs-ehsgl-nt\apps\envisions\reports\5021.rpt <br />