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Date run 7/16/2015 1:22:11 PN SAI AQUIN COUNTY ENVIRONMENTAL 1�LTH DEPARTMENT Report#5021 <br /> Run by • t Pagel <br /> Facility Information as of 7/16/2015 <br /> Record Selection Cntena: Facility ID FA0002246 <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 OW0003026 New Owner ID <br /> owner Name FEDERICO, ERNIE & MARIA <br /> Owner DBA <br /> Owner Address 800 E ORFORD ST <br /> STOCKTON, CA 95215 <br /> Home Phone 209-368-8131 <br /> Work/Business Phone 209-368-8131 <br /> Mailing Address 800 E ORFORD ST <br /> STOCKTON, CA 95215 <br /> Care of FEDERICO, ERNIE& MARIA <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0002246 <br /> Facility Name PERKOS CAFE <br /> Location 4300 E WATERLOO RD <br /> STOCKTON, CA 95215 <br /> Phone 209-931-5611 <br /> Mailing Address 4300 E WATERLOO RD <br /> STOCKTON, CA 95215 <br /> Care of FEDERICO, ERNIE & MARIA <br /> Location Code 99- UNINCORPORATED A Alt Phone <br /> BOS District 002- MILLER, KATHERINE Fax <br /> APN 10118033 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name FEDERICO, ERNIE & DEANNA <br /> Title <br /> Day Phone 209-931-5611 <br /> Night Phone 209-931-5611 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002258 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name PERKOS CAFE (Circle One) <br /> Account Balance as of 7/16/2015: $0.00 <br /> (Circle One) <br /> Transferto ActivWlnacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1626-RESTAURANT/BAR 101 +SEATS PRO161814 EE0008999-LEYNA HUYNH Active Y N A I D <br /> 3116-STORMWATER INSPECTION-FOOD PR0522949 EE0006213-VIDAL PEDRAZA Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and'or project specific,PHSIEHD hourly charges associated with this facility or: <br /> be billed to the party identified as the ONMER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and'or Standards 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 Type Check Number Received by <br /> EHD Staff: Date / / Account out: Date <br /> COMMENTS: Invoice#: <br />