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Report%5021 <br /> Pagel <br /> oats run 10/5/2015 1:24A4PP sAN JO <br /> AQUIN COUNTYFacility Information as of 10/512015 <br /> DEPARTMENT <br /> Run by <br /> FA0018527 <br /> Record selection Cdleda'. FaGI1N ID <br /> Make changesicorrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) �— <br /> OWNER FILE INFORMATION Number of facilities for this owner: 10 SSN/Fed Tax ID <br /> owner ID OWO011043 New Owner lD <br /> owner Name BON APPETIT MGMT CO <br /> Owner DBA <br /> owner Address 100 HAMILTON AVE 400 <br /> PALO ALTO, CA 94301 <br /> Home Phone 650-798-8000 <br /> Work/Business Phone 209-460-3890 <br /> Mailing Address 100 HAMILTON AVE STE 400 <br /> PALO ALTO, CA 94301 <br /> care of MOHSENZADEGAN, SIA <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0018527 <br /> Facility Name DAVEY CAFE <br /> Location 3601 PACIFIC AVE <br /> STOCKTON, CA 95211 <br /> Phone 209-946-2264 Mailing Address 901 PRESIDENTS DR <br /> STOCKTON, CA 95211 t6,16 AHb <br /> Care of MOHSENZADEGAN, SIA <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 11314009 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SIAMOHSENZADEGAN <br /> Title <br /> Day Phone 209-460-3890 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0032773 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to Owner / Facility / Account <br /> Account Name DAVEY CAFE (Circle One) <br /> Account Balance as of 10/5/2015: $0.00 <br /> (Circe One) <br /> Transferto Activellname <br /> PrgmmlElement and Descdption Record ID Employee ID and Name Status New Owner? Delete <br /> 1623-RESTAURANT/BAR 1-20 SEATS PRO527366 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> 1634-FOOD VEHICLE/CART(PREPKGD ONLY) PRO527367 EE0003361 -MARIBEL FLOHRSCHUTZ Active 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 Nis facility <br /> or activity will be billed to the party identified as the OWNER on they form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State anb'or <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / / <br /> Water System to be TRANSFERED: Amount Paid Date / I <br /> Payment Type Check Number Received bx <br /> EHD Staff. Date—/—/— Account out: Date�l�/_Z-L� <br /> COMMENTS'. <br /> Invoice#: <br />