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Facility Information as of 12/6/2017 Page1Run by 12/6/2017 1:32:59PM Report #5021Date run FA0018699Facility IDRecord Selection Criteria: SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT OWNER FILE INFORMATION Owner Address Owner DBA Owner Name Owner ID Home Phone Work/Business Phone Mailing Address Care of New Owner ID : _____________________________ Make changes/corrections in RED ink. INFORMATION CHANGE (date) ___________________ OWNERSHIP CHANGE (date) ___________________ OW0015366 Sojojkm LLC SQUEEZE INN ACAMPO, CA 95220 209-368-1271 209-833-7992 2742 Naglee Rd. DAVIS, DEAN B Tracy, CA 95304 _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ SSN / Fed Tax ID : _____________________________ 6373 E PELTIER RD Number of facilities for this owner : 1 FACILITY FILE INFORMATION Facility ID / CERS ID Facility Name Location Phone Mailing Address Care of Location Code BOS District FA0018699 Squeeze Inn Tracy, CA 95304 209-833-7992 x 2742 Naglee Rd Dean Davis Tracy, CA 95304 005 - ELLIOTT, BOB 03 - TRACY _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ Alt Phone Fax _________________________________________ _________________________________________ _________________________________________ _________________________________________ _________________________________________ EMail : _________________________________________ 21229008APN 10636690 2742 Naglee Rd EMERGENCY NOTIFICATION CONTACT INFORMATION Night Phone Day Phone Title Contact Name DEAN B DAVIS 209-833-7992 209-368-1271 _________________________________________ _________________________________________ _________________________________________ _________________________________________ ACCOUNTS RECEIVABLE FILE INFORMATION Account ID Mail Invoices to Account Name New Account ID: : _______________________ Mail Invoices to: Owner / Facility / Account (Circle One) Program/Element and Description Record ID Employee ID and Name Status Transfer to New Owner? Account AR0033172 Sojojkm LLC Account Balance as of 12/6/2017: $0.00 (Circle One) Active/Inactve Delete 1624 - RESTAURANT/BAR 21-50 SEATS PR0527596 EE0001420 - MELISSA NISSIM Active Y N A I D 1919 - HMBP-CO2 Only Food Facility PR0540288 EE0001420 - MELISSA NISSIM Active Y N A I D COMMENTS: APPLICANT'S SIGNATURE: __________________________________________________________ Date ______/______/______ Program Records to be TRANSFERED: __________ * $25.00 = __________ Amount Paid __________ Date ______/______/______ Water System to be TRANSFERED: _________________________________ Amount Paid __________ Date ______/______/______ Payment Type ________________ Check Number ____________________________________ Received by _____________________ EHD Staff: ___________________________________ Date ______/______/______ Account out: _____________ Date ______/______/______ BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility 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 and/or Federal Laws. Invoice #: _______________________