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Dale run 7/3/2018 4:30:48PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by M OZUNA Pagel <br /> Facility Information as of 7/3/2018 <br /> Record Selection Criteria: Facility ID FA0023549 <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: 1 SSN/Fed Tax ID <br /> Owner ID OW0021839 New Owner ID <br /> Owner Name QUESADA, MARIA LUCRECIA <br /> Owner DBA <br /> Owner Address 2566 DOUGLAS FIR DR 6 <br /> A 711 <br /> LODI, CA 95242 <br /> Home Phone 209-642-6095 <br /> Work/Business Phone 209-263-7359 <br /> Mailing Address 3034 CELEBRATION DR <br /> LODI, CA 95242 L <br /> Care of QUESADA, MARIA LUCRECIA <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0023549 <br /> Facility Name CRYSTAL ROSE CONFECTIONERY <br /> Location 2566 DOUGLAS FIR DR 30# a P Qn ilk 2 <br /> LODI, CA 95242 S� <br /> Phone 209-642-6095 <br /> Mailing Address 3034 CELEBRATION DR <br /> LODI, CA 95242 �y7 <br /> Care of QUESADA, MARIA <br /> Location Code 02- LODI Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name QUESADA, MARIA <br /> Title <br /> Day Phone 209-642-6095 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0043460 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name CRYSTAL ROSE CONFECTIONERY (Circle One) <br /> Account Balance as of 7/3/2018: $0.00 <br /> (Circle One) <br /> Progrsrn/Element and DescriptionRewrtl ID Employee ID and Name Status Transfer to Active/InacNe <br /> New Owner? Delete <br /> 1609-CLASS B COTTAGE FOOD-INDIRECT SALES PRO541126 EE0001084-STEPHANIE RAMIREZ Active Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,Me undersigned owner,operator or agent of same,aoknomedge that all site,andor project specific,PHSIEHD 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 andor Standards and State ander <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 <br /> EHD COMMENTS: <br /> Date / / Account out: Date <br /> COMMENTS: <br /> Invoice#: <br /> S <br />