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Date run 5/2/2019 4:18:51PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 5/2/2019 <br /> Record Selection Criteria: Facility ID FA0001285 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0015870 New Owner ID <br /> Owner Name FRANCO, GENOBEVO <br /> Owner DBA FLAMINGO NIGHT CLUB <br /> OwnerAddress 1912 BRIENZ WAY <br /> MANTECA, CA 95337 <br /> Work/Business Phone 562-499-9370 <br /> Alternative Phone 209-239-9141 <br /> Mailing Address 1912 BRIENZ WAY <br /> MANTECA, CA 95337 <br /> Care of FRANCO, DELMA <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0001285 <br /> Facility Name FLAMINGO NIGHT CLUB <br /> Location 1233 E CHARTER WAY <br /> STOCKTON, CA 95205 <br /> Phone 209-239-9141 xHOME/OFFIC <br /> Mailing Address 1233 E CHARTER WAY <br /> STOCKTON, CA 95205 <br /> Care of GENOBEVO OR DELMA FRANCO <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, MIGUEL Fax <br /> APN 15137018 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name GENOBEVO FRANCO <br /> Title <br /> Day Phone 562-499-9370 Cell <br /> Night Phone 209-239-9141 xHOME/( <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0001283 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name FLAMINGO NIGHTCLUB (Circle One) <br /> Account Balance as of 5/2/2019: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1626-RESTAURANT/BAR 101 +SEATS PRO161494 EE0009832-VICTOR ACEVEDO Inactive Y N A I D <br /> 2066-MILK DISPENSER PR0200232 EE0009374-LARRY GODINHO Inactive 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,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 and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S 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 Received by <br /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />