Laserfiche WebLink
Date run 11/25/2013 2:29:14P SAN JC UIN COUNTY ENVIRONMENTAL HEA I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 11/25/2013 <br /> Record Selection Criteria: Facility ID FA0004627 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0003522 New Owner ID <br /> Owner Name TRAVERSO, VIRGIL L <br /> Owner DBA SAN FELIPE GRILL <br /> Owner Address 3875 PENINSULA CT <br /> STOCKTON, CA 95219 <br /> Home Phone 209-478-2146 <br /> Work/Business Phone Not Specified <br /> Mailing Address 4601 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0004627 <br /> Facility Name SAN FELIPE GRILL <br /> Location 4601 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Phone 209-952-6261 <br /> Mailing Address 4601 PACIFIC AVE <br /> STOCKTON, CA 95207 <br /> Care of TRAVERSO, VIRGIL L <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 11023007 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name TRAVERSO, VIRGIL L <br /> Title <br /> Day Phone 209-952-6261 <br /> Night Phone 209-478-2146 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004956 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility ! Account <br /> Account Name SAN FELIPE GRILL (Circle One) <br /> Account Balance as of 11/25/2013: $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 /> 1624-RESTAURANT/BAR 21-50 SEATS PR0500130 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A O D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor 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 andror <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 T pe _ Check Number Received by <br /> RENS: GLt r rf Date �� / �J / "j Account out: Date <br /> COMMENTS: <br /> /1�a�t l/3 1irn p �s /3 -t v-er�- <br /> r,,jas <br />