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Date run 7/27/2018 12:06:09PI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run-by Pagel <br /> Facility Information as of 7/27/2018 <br /> Record Selection Criteria: Facility ID FA0023849 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0022247 New Owner ID <br /> Owner Name MAGANA, KATHY <br /> Owner DBA DUO DELIGHTS <br /> OwnerAddress 5522 COSUMNES DR <br /> STOCKTON, CA 95219 <br /> Home Phone 209-405-5299 <br /> Work/Business Phone Not Specified <br /> Mailing Address 5522 COSUMNES DR <br /> STOCKTON, CA 95219 <br /> Care of MAGANA, KATHY <br /> FACILITY FILE INFORMATION <br /> Facility ID 1 CERS ID FA0023849 <br /> Facility Name DUO DELIGHTS <br /> Location 5522 COSUMNES DR <br /> STOCKTON, CA 95219 <br /> Phone 209-405-5299 <br /> Mailing Address 5522 COSUMNES DR <br /> STOCKTON, CA 95219 <br /> Care of MAGANA, KATHY <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name MAGANA, KATHY <br /> Title <br /> Day Phone 209-405-5299 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0044200 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner I Facility I Account <br /> Account Name DUO DELIGHTS /1 x.,11 (Circle One) <br /> Account Balance as of 7/27/2018: $292.00 <br /> (Circle One) <br /> Transferto Active[Inactve <br /> ProgramIFIement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1608-CLASS A COTTAGE FOOD-DIRECT SALES PRO541609 EE0001084-STEPHANIE RAMIREZ Active Y N A f I/ / D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSfEHD hourly charges associated with this facility <br /> or activity wilt 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 andfor Standards and State andlor <br /> Federal Laws, <br /> APPLICANT'S SIGNATURE: Date 1 1 <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 1 <br /> Water System to be TRANSFERED: Amount Paid Date I I <br /> Payment Type Check Number Received b <br /> EHD Staff: ah- Date I 'li� 1 ( Account out: 6 Date 9'1�1 <br /> COMMENTS: Invoice#: <br /> 1ti�1 till �o�al��l v� l,a C1 a- av\a o�u✓Vqk. i,vo_�_ jr <br /> ham' �'e I414- 0"' 111 vvrr,� <br /> �•�,I ' c� 1 `�J is s�il� AuHa' ?UA It— I.VNAt'll virvk . <br />