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Date run 10/6/2016 2:05:26PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/6/2016 <br /> Record Selectlon Criterla: Facility ID FA0006386 <br /> Make changeslcorrections in RED ink. O <br /> INFORMATION CHANGE(date) / Cv to <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN 1 Fed Tax ID : <br /> Owner ID OW0001207 New Owner ID <br /> Owner Name BUENROSTRO, SALVADOR <br /> Owner DBA CALIFORNIA CATERING TRUCK WASH <br /> OwnerAddress 2717 ANGEL DR <br /> STOCKTON, CA 95209 <br /> Home Phone 209-271-1741 <br /> Work/Business Phone 209-464-9707 <br /> Mailing Address 2717 ANGEL DR <br /> STOCKTON, CA 95209 <br /> Care of CALIFORNIA CATERING TRUCK WASH <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0006386 10182091 <br /> Facility Name CALIFORNIA CATERING TRUCK WASH <br /> Location 730 S CALIFORNIA ST <br /> STOCKTON. CA 95203 <br /> Phone 209-464-9707 <br /> Mailing Address 730 S CALIFORNIA ST <br /> STOCKTON, CA 95203 <br /> Care of BUE U C-d o <br /> Location Code 01 -STOCKTON Alt Phone <br /> Bos District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 14723003 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name BUENROSTRO, SALVADOR <br /> Title <br /> Day Phone 209-464-9707 <br /> Night Phone 209-464-9707 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0007812 New Account 1D: <br /> Mail Invoices to Owner Mail Invoices to: Owner 1 Facility 1 Account <br /> Account Name BUENROSTRO, SALVADOR (Circle One) <br /> Account Balance as of 10/6/2016-. $0.00 <br /> (Circle One) <br /> Transfer to Activellnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owrl Delete <br /> 1680-COMMISSARY(MFPU&FOOD PREP) PR0504885 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> 1920-HMBP-Common Materials PR0522039 EE0009817-ROBERT LOPEZ Active Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0532446 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOIA&EDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHVEHD 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'ar <br /> Federal Laws- <br /> APPLICANT'S SIGNATURE: Date 1 / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / 1 <br /> Water System to be TRANSFERED: Amount Paid Date 1 1 <br /> Payment Typ Check Number Received by <br /> EHD Staff: L4PA Z Date_0- 1��I Account out: Date <br /> COMMENTS: <br /> Invoice : <br />