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lw <br />lwReport#5021 <br />Date run 7/18/2019 3:13:04PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL�EPARTMENT <br />Run by Paget <br />Facility Information as of 7/18/2019 <br />Record Selection Criteria: Facility to FA0025098 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID OW0023764 <br />Owner Name BROWN, PEDRO <br />Owner DBA THE PIRATES LOUNGE TATTOO PARLOR <br />Owner Address 819 N EDISON ST <br />STOCKTON, CA 95203 <br />Work/Business Phone Not Specified <br />Alternative Phone 608-432-1770 <br />Mailing Address 819 N EDISON ST <br />STOCKTON, CA 95203 <br />Care of BROWN, PEDRO <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0025098 <br />Facility Name <br />THE PIRATES LOUNGE TATTOO PARLOR <br />Location <br />2714 COUNTRY CLUB BLVD <br />STOCKTON, CA 95203 <br />Phone <br />209-451-3900 <br />Mailing Address <br />819 N EDISON ST <br />STOCKTON, CA 95203 <br />Care of <br />BROWN, PEDRO <br />Location Code <br />01-STOCKTON <br />BOS District <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name BROWN, PEDRO <br />Title <br />Day Phone 209-451-3900 <br />Night Phone 209-432-1770 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0047157 <br />Mail Invoices to Account <br />Account Name THE PIRATES LOUNGE TATTOO PARLOR <br />Arrount Balance as of 7/18/2019: $152.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN /Fed Tax ID <br />New Owner ID : _ <br />Alt Phone <br />Fax <br />EMaii : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to ActiveAnactve <br />ProgramlElement and Description Record to Employee to and Name Status New Owner? Delete <br />4110 - BODY ART PRACTITIONER REGISTRATION PRO544139 EE0000036 - NAVJOT SAHOTA Active Y N A0 D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1, the undersigned owner, operator or agent of same, admowledge that all site, and/or project specific. PHSIEHD hourly charges associated with this facility <br />or activity will be billed to the party identified as the OWNER on this form 1 also certify that all operations will be performed in accordance with all applicable Ordinance Codes andtor Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Date / 1 <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date / J <br />Water System to be TRANSFERED: Amount Paid Date t / <br />Payment Type Check Number Received b <br />EHD Staff: AQIA . Date �_/�/, Account out: __ Date �_/Pf <br />COMMENTS: Invoice #: <br />CONFIDENTIAL <br />