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i <br /> Dat%run t 819/2017 8:21:17AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Pagel <br /> Run by <br /> Facility Information as of 8/9/2017 <br /> Record Selection Criteria: Facility ID FA0000702 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 2 SSN 1 Fed Tax ID <br /> Owner ID OW0000560 New Owner ID <br /> Owner Name KNIGHT, PETER &ANNETTE <br /> Owner DBA A&W ROOT BEER OF LODI <br /> OwnerAddress 216 E LODI AVE <br /> LODI, CA 95240 <br /> Home Phone 209-366-2914 <br /> Work/Business Phone 209-368-8548 <br /> Mailing Address 216 E LODI AVE <br /> LODI, CA 95240 <br /> Care of A&W ROOT BEER OF LODI <br /> FACILITY FILE INFORMATION <br /> Facility IDICERS ID FA0000702 <br /> Facility Name A&W ROOT BEER OF LODI <br /> Location 216 E LODI AVE <br /> LODI, CA 95240 <br /> Phone 205-368-8548 <br /> Mailing Address 216 E LODI AVE <br /> LODI, CA 95240 <br /> Care of A&W ROOT BEER OF LODI <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 04719103 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact dame KNIGHT, PETERIANNETTE <br /> Title <br /> Day Phone 209-368-8548 <br /> Night Phone 209-366-2914 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000701 New Account ID: <br /> Mai€Invoices to Facility Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name A&W ROOT BEER OF LODI (Circle One) <br /> Account Balance as of 81912017: $0.00 <br /> f G] (Circle One) <br /> T, <br /> ! Transfer to Activeftnaclve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO161769 EE0009488-JEFFREY WONG Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT, I,the undersigned owner,operator or agent of same,acknowledge that a site,and/or project specific,PHSfEHD 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 wifl be performed in accordance with all applicable Ordinance Codes andror Standards and State and/or <br /> Federal Laws <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date I 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Type Check Number Received by <br /> EHD Sta€f: Date 1 1 Account out: Date 1 1 <br /> COMMENTS: Invoice#: <br />