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Date ran 6/6/2018 5:05:16PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/6/2018 <br /> Record Selection Criteria: Facility ID FA0023849 <br /> Make changestcorrections 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 209405-5299 <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/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 NewAccount ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name DUO DELIGHTS (Circle One) <br /> Account Balance as of 6/6/2018: $292.00 <br /> (Circle One) <br /> Transfer to Actherinache <br /> Program/Element and Description Record ID Employee ID and Name Status New Own.f CI <br /> 1608-CLASS A COTTAGE FOOD-DIRECT SALES PR0541609 EE0001084-STEPHANIE RAMIREZ Active Y N A / I \ D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: Lthe undersigned owner,operator or agent of same,acknowledge Nat all site,andror project specific PHSIEHD hourly charges associated with acility, <br /> or adivity,will be billed to the party identKeci as the OWNER an this form. I also certify,that all operations will be performed in accordance with all applicable Ordinance Codes andlor Standards and State anNor <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / / <br /> Water System to b TRANSFER Amount Paid Date <br /> Payment Type heck lumber Received by <br /> EHD Staff: Date / / Account out: Date / / <br /> COMTNTS: <br /> IZ ( fid ca(U0( 6peW4 V m4x �L� d/Yt OtJI�/vt� Invoice#: <br /> tti+ td �H�G�,�alc i O�i� n hlA✓ hRc% �m <br /> ���AV& <br />