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Daterun 11115/2021 3:45:44PK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1/15/2021 <br /> Record Selection Criteria: Facility ID FA0001700 <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 OW0001332 New Owner ID <br /> Owner Name V& K PATEL INC <br /> Owner DBA RELAX INN <br /> OwnerAddress 1604 N WILSON WAY <br /> STOCKTON, CA 95205 <br /> Work/Business Phone Not Specified <br /> Alternative Phone 916-214-1554 <br /> Mailing Address 1604 N VILSON WAY <br /> ST TON, CA 95205 <br /> Care of V& K PATEL INC <br /> FACILITY FILE INFORMATION APN 11727025 <br /> Facility ID/CERS ID FA0001700 <br /> Facility Name RELAX INN <br /> Location 1604 N WILSON WAY <br /> STOCKTON, CA 95205 <br /> Phone 916-214-1554 <br /> Mailing Address 1604 N W <br /> jLSM WAY T <br /> STO ON, CA 95205 957 NFE 1260CZ010000�1/ 7 z� <br /> Care of V& KPATEL INC _� D_ <br /> ' RELAX INN V $r K PATEL <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION 1z L> E CO ST <br /> CAL.. XI CO CA 92231-2638 <br /> Contact Name AHMAD, FARUKH R <br /> RETURN TO SENDER <br /> Title <br /> Day P Phone 209-670-5559 Cell Il�l�tl::litll�li�:l��t111:;:ltiillilt"!�!l�I�!'!11'��l,�11i19i� <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0001699 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name RELAX INN (Circle One) <br /> Email invoice to(up to 2 emails) <br /> Email permit to(up to 2 emails) <br /> Account Balance as of 1/15/2021: $304.00 <br /> (Circle One) <br /> Transferto Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner7 Delete <br /> 1623-RESTAURANT/BAR 1-20 SEATS PR0534925 EE0078788-GEHANE FAHMY Inactive Y N A I D <br /> 2417-HOTEL/MOTEL 26-50 PR0240087 EE0002089-OMRAN SOOD Active Y N A V D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror 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 andror Standards and State andlor <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 /> EHDStaff: , Date 0 ( /�_/ 2 LiAccountout: Date / / y" I <br /> COMMENTS: <br /> W ' / InV01Ce#: <br /> f`i`ll/////// q vl <br />