Laserfiche WebLink
Date run 7/8/2015 4:00:24PM SAN J( 1UIN COUNTY ENVIRONMENTAL HEA- -H DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 7/8/20 10 <br />Record Selection Criteria: Facility ID FA0018699 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0015366 <br />Owner Name <br />SOJOJKM LLC <br />Owner DBA <br />SQUEEZE INN <br />Owner Address <br />9567 E ACAMPO RD <br />ACAMPO, CA 95220 <br />Home Phone <br />209-368-1271 <br />Work/Business Phone <br />209-833-7992 <br />Mailing Address <br />9567 E ACAMPO RD <br />ACAMPO, CA 95220 <br />Care of <br />DAVIS, DEAN B <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID FA0018699 <br />Facility Name SQUEEZE INN <br />Location 2742 NAGLEE RD <br />TRACY, CA 95304 <br />Phone 209-833-7992 <br />Mailing Address 2742 NAGLEE RD <br />TRACY, CA 95304 <br />Care of DEAN B DAVIS <br />Location Code 03 -TRACY <br />BOS District 005 - ELLIOTT, BOB <br />APN 21229008 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name DEAN B DAVIS <br />Title <br />Day Phone 209-833-7992 <br />Night Phone 209-368-1271 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0033172 <br />Mail Invoices to Facility <br />Account Name SQUEEZE INN <br />Account Balance as of 7/8/2015: $0.00 <br />Make changesicorrections in RED ink. _ <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />1 SSN /Fed Tax ID <br />New Owner ID : <br />Ik <br />I <br />Alt Phone <br />Fax <br />EMail : <br />New Account ID: : <br />Mail Invoices to: Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1624 - RESTAURANT/BAR 21-50 SEATS PR0527596 EE0001420 - MELISSA NISSIM Active Y N A I D <br />1921 - HMBP-Regular-Primary Location PR0540288 EE0000010 - PETER LOMBARDI Active Y N O I D <br />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 <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 and/or Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: k& ".—A, A. &ZO Date 7 / I / l 16 <br />Program Records to be TRANSWED: ' $25.00 = Amount Paid Date <br />ANSfE <br />Water System to be R: Amount Paid Date <br />Payment Type Check Number Received by <br />EHD / � Staff: %r Date / / Account out: Date V'/ / <br />COMMENTS: <br />Invoice #: <br />