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Date run 12/15/2010 3:49:08P <br /> SAN JO JIN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run byPagel <br /> Facility Information as of 12/15/2010 <br /> Record Selection Criteria; FacilityID FA0000893 <br /> Make changes/corrections in RED Ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0003043 New Owner ID <br /> Owner Name SHAHEN, MARCUS <br /> Owner DBA COOL WATER RESTAURANTS INC <br /> Owner Address 2205 WARM SPRINGS DR <br /> MODESTO, CA 95356 <br /> Home Phone 209-610-8430 <br /> Work/Business Phone 209-578-9951 <br /> Mailing Address 2205 WARM SPRINGS DR <br /> MODESTO, CA 95356 <br /> Care of SHAHEN, MARCUS <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0000893 <br /> Facility Name TOMMYS BEACH BAR & GRILL <br /> Location 1351 W YOSEMITE AVE <br /> MANTECA, CA 95337 <br /> Phone 209-823-1961 <br /> Mailing Address 1351 W YOSEMITE AVE <br /> MANTECA, CA 95336 <br /> Care of SHAHEN, MARCUS <br /> Location Code 04 - MANTECA Alt Phone <br /> BOS District 003- BESTOLARIDES Fax <br /> APN 20015021 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SHAHEN, MARCUS <br /> Title <br /> Day Phone 209-823-1961 <br /> Night Phone 209-578-9951 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0000890 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name TOMMYS BEACH BAR & GRILL (circle one) <br /> Account Balance as of 12/15/2010: $69.00 <br /> (Circle One) <br /> Transferto Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1626-RESTAURANT/BAR 101 +SEATS PRO161154 EE0003474-CHANDRA OM Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all she,and/or project specific,PHS/EHO hourly charges associated with this <br /> 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 Ordinace Codes and/or Standards and <br /> Stale anclor 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 by <br /> REHS: C l Vy I--4 6 M Date,IA—j-"] .10 Account out: C— Date \\o / VD <br /> COMMENTS: <br /> \\eh-env\envis ion\reports\5021.rpt <br />