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Date run 1/3/2018 2:41:53PM SAN JOAQUIN C(IUr.!*Y ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1/3/2018 <br /> Record Selection Criteria', Facility ID FA0001738 <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 OW0001352 New Owner ID <br /> Owner Name SBRAGIA, LARRY <br /> Owner DBA BASILS PLACE <br /> OwnerAddress 2324 GRAND CANAL 4 <br /> STOCKTON, CA 95207 <br /> Home Phone 209-473-1626 <br /> Work/Business Phone 209-478-6290 <br /> Mailing Address 2324 GRAND CANAL#4 <br /> STOCKTON, CA 95207 <br /> Care of LARRY SBRAGIA <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0001738 10180803 <br /> Facility Name BASILS PLACE <br /> Location 2324 GRAND CANAL BLVD#4 <br /> STOCKTON, CA 95207 <br /> Phone 209-478-6290 x <br /> Mailing Address 2324 GRAND CANAL#4 <br /> STOCKTON, CA 95207 <br /> Care of BASIL'S PLACE <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 11007016 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name BASILS PLACE <br /> Title <br /> Day Phone 209-478-6290 <br /> Night Phone 209-478-6290 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0001737 NewAccount ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name BASILS PLACE (Circle One) <br /> Account Balance as of 1/3/2018: $0.00 <br /> (Circle One) <br /> Transfer to Activelinachn, <br /> Program/Element and Description Record ID Employee ID and Name Status Naw nwnen Delete <br /> i6! 24-}2ESTAURANT/BAR 21-50 SEATS PRO160391 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> (� HMBP-Regular-Primary Location PR0530819 EE0008709-2!A A fnr, Active Y N A I D <br /> 1` RSC-ELECTRONIC REPORTING STATE SURCHARGI PR0532276 I I Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHSrEHD hourly charges associated with this <br /> facility or activity will be billed to the party identified as the OWNER on this form. I also ceM1dy that all operations will be performed in accordancewith all applicable Ordinance Codes andor Standards <br /> and State andor 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 Tye /; ^ Check <br /> .NI um}1b'jerI R <br /> eceived by <br /> EHD Staff. UWL _ DateAccount out: <br /> Date / / <br /> COMMENTS <br /> / <br /> IDVOICe 7f: <br />