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Date nn Report#5021 7/21/2017 1:32:OSPN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Pagel <br /> Run by <br /> Facility Information as of 7/21/2017 <br /> Record Selection Criteria: Facility ID FA0003169 <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: 2 SSN/Fed Tax ID <br /> Owner ID OW0002365 New Owner ID <br /> Owner Name MELENDEZ, DANIEL D <br /> Owner DBA M &V MEXICAN FOOD INC <br /> OwnerAddress 1820 TAHOE CIR <br /> TRACY, CA 95376-8915 <br /> Home Phone 209-629-8608 <br /> Work/Business Phone 209-386-3933 <br /> Mailing Address 1765 HUMMINGBIRD WAY <br /> TRACY, CA 95376-6756 <br /> Care of DANIEL MELENDEZ <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0003169 10645417 <br /> Facility Name TAQUERIALAMEXICANA#1 <br /> Location 1284 W ELEVENTH ST <br /> TRACY, CA 95376 <br /> Phone 209-833-6343 <br /> Mailing Address 1284 W 11TH ST <br /> TRACY, CA 95376 <br /> Care of DANIEL MELENDEZ <br /> Location Code 03 -TRACY Alt Phone <br /> BOS District 005-ELLIOTT, BOB Fax <br /> APN 23405008/9 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name DANIELMELENDEZ <br /> Title <br /> Day Phone 209-833-6343 <br /> Night Phone 209-386-3933 Cell <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002734 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name TAQUERIALAMEXICANA#1 (Circle One) <br /> Account Balance as of 7/21/2017: $0.00 <br /> (Circe One) <br /> Transfer to ActiwAnacNe <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1624-RESTAURANT/BAR 21-50 SEATS PR0161438 EE0001420-MELISSA NISSIM Active Y N A I D <br /> 1919-HMBP-0O2 Only Food Facility PRO540351 EE0001420-MELISSA NISSIM Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party,Identified as the OWNER on this form. I also certfij that all operations will be performed in accordance with all applicable Ordinance Codes ander Standards and State andfor <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 <br /> Payment Type Check Number Received by <br /> EHD Staff: Date_/ / Account out: Date <br /> COMMENTS: Invoice#: <br />