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Date run 12/5/2016 4:59:47PR SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/5/2016 <br /> Record Selection Criteria: Facility ID FA0021031 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) 10 <br /> L <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0017309 New Owner ID : <br /> Owner Name FE{�q_ 6 � E �r C" / <br /> Owner DBA CANELO'S MARKET �T <br /> OwnerAddress 2031 S ELDORADO ST <br /> STOCKTON, CA 952062733 <br /> Home Phone Not Specified <br /> Work/Business Phone 209-981-2538 <br /> Mailing Address 2031 S ELDORADO ST <br /> STOCKTON, CA 952062733 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0021031 10187737 <br /> Facility Name CANELO'S MARKET <br /> Location 2031 S EL DORADO ST <br /> STOCKTON, CA 952062733 <br /> Phone 209-462-4763 x0 <br /> Mailing Address 2031 S ELDORADO ST <br /> STOCKTON, CA 952062733 <br /> Care of <br /> Location Code Alt Phone <br /> BOB District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 16514411 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0037850 NewAccount ID: <br /> Mail Invoices to Ownern Mail Invoices to: Owner / Facility / Account <br /> Account Name F (Circle One) <br /> Account Balance as of 12/5/2016: $0.00 <br /> (Circle One) <br /> Transfer to Activeinactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1920-HMBP-Common Materials PRO536623 EE0009817-ROBERT LOPEZ Active Y N A © D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PR0536767 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project speck,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the perry identhed as the OWNER on this form. I also certify that ell operations will be performed in accordance with all applioable Ordinance Codes andlor Standards and State andror <br /> 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 / I <br /> Payment Type Check Number Received y <br /> EHD Staff: 'L-- Date L / / //i Account out: Date <br /> COMMENTS: If <br /> Invoice#: <br />