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Datepn , 1, 11/2015 8:50:50A SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Ibrown Pagel <br /> Facility Information as of 12/11/2015 <br /> Record Selection Criteria: Facility ID FA0018527 <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: 10 SSN I Fed Tax ID <br /> Owner ID OW0011043 New Owner ID <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 _ lib ut-f-`D P_ <br /> PALO ALTO, CA 94301 SfD 44L-tDrn 6ft 45--XI1 <br /> Care of MOHSENZADEGAN, SIA <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0018527 <br /> Facility Name DAVEY CAFE <br /> Location 3601 PACIFIC AVE <br /> STOCKTON, CA 95211 <br /> Phone 209-946-2264 <br /> Mailing Address 100 HAMILTON AVE STE 400 QD 1 PraidGA4 j}2 <br /> PALO ALTO, CA 94301 -5ta LKfT n <br /> Care of MOHSENZADEGAN, SIA li%R Dtfi ' <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 SIA MOHSENZADEGAN <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 1 Facility / Account <br /> Account Name DAVEY CAFE (Circle One) <br /> Account Balance as of 1211112015: $0.00 <br /> (Circle One) <br /> Transfer to Active!lnactve <br /> ProgramlEtementond Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1623-RESTAURANT/BAR 1-20 SEATS PR0527366 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> 1634-FOOD VEHICLEICART(PREPKGD ONLY) PRO527367 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSIEHD hourly charges associated with this faoilily <br /> or activity will be billed to the party identified as the OWNER en this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State ardor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE; Date 1 ! <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date I ! <br /> Water System to be TRANSFERED: Amount Paid Date I I <br /> Payment Type Check Number Received by -im— _ <br /> EHD Staff; Date / / Account out: ��_ Date <br /> COMMENTS: <br /> Invoice#: <br /> • <br />