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Date run 5/f 1/2018 2:56:00M SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Run bq Report#5021 <br /> Facility Information as of 5/11/2018 Pagel <br /> Record Selection Caere: Facility ID FA0000267 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) r <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SS / edTaxl 01— ���i� �Z© 7 <br /> Owner ID OW0005328 New Owner ID -� <br /> Owner Name EDWARDS, GERALDINE _Y060 /��h fit` g 1NVPc MSN �� n� <br /> Owner DBA `MARYSMIP MARKET /,/I I<c1. rrkI) <br /> Owner Address p X601 2-15<6 2-- j ber Fv Rc� <br /> Home Phone CLEMFN �g5227 2 C Qvtt est C fSlL� <br /> 650-484 <br /> Work/Business Phone_: _7.69-301 4 S �� <br /> Mailing Address PO BOX 601 07i ( 5'7g .o 1 <br /> CLEMENTS, CA 95227 <br /> Care of 9322`-T <br /> _ Pun_PN 4 <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0000267 _ 4�9 MQ r KI e t Grv< I I <br /> Facility Name -22 <br /> Location 21882 E LIBERTY RDp <br /> CLEMENTS, CA 95227 �mw 2a C ?r� <br /> Phone 9119 769 8014 <br /> Mailing Address O BO <br /> NTS, CA 95227 <br /> Careof EDWARDS, GERALDINE <br /> Location Code 99 - UNINCORPORATED P Alt Phone 0 9 3 <br /> BOS District 004-WINN, CHARLES Fax 2ac( <br /> APN 02120024 EMail: jNvfS WIPPi 4 II <br /> tvl C a u�taO.fp� <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name <br /> Title <br /> Day Phone �J/MEN'� 2D9 ^15y 31I Y <br /> Night Phone pnG^G`�o 2D4 (o $�I 't�- <br /> ACCOUNTS RECEIVABLE FILE INFORMATION �` �p1t <br /> Account ID AR0008849 MA� 1 1 uNSS New Account ID(Facilit <br /> Mail Invoices to Facility v1N�SPti Mail Invoices to: Owner / Account <br /> Account Name MARYS MINI MARKET 30!`4;M N M6� ImI nal <br /> Account Balance as of 5/11/2018: $0.00 `+�EtyV S9lititiP <br /> (1In '`'{rte N (Circle One) <br /> Rill'aNl Descdpbon Record lD Transferto Activenractve <br /> 1 Employee ID and Name Status New Owner? Delete <br /> 1 5- TAIL MKT 301-2000 SO FT(PREPKGD/LTD PF PRO161863 EE0078788-GEHANE FAHMY Inactive Y N 7i I D <br /> 5 -UST FACILITY-2481 COMPLIANT PRO528163 EE0000030-AARON HANG Inactive Y N I D <br /> 4616-TNC WATER SYSTEM-CalCODE PR0542722 EE0001084-STEPHANIE RAMIREZ Inactive Y N I D <br /> 4616-TNC WATER SYSTEM-CaICODE WA0515487 EE0001084-STEPHANIE RAMIREZ InactI D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the party identifiedAD: � <br /> Ials cert' that all operations will be performed in accordance with all applicable Ordinance Codes andvor Standards and Stale an or <br /> Federal Laws. L <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSF $25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid37G-CD D <br /> Payment Type V I t-A. Check NumberReceived b <br /> EHD Staff: Date_/_/_ Account out: Date Z/ lL <br /> COMMENTS: <br /> Invoice#: 30 0S-F� <br /> 9f � 3�G•� .��- `l t l 1$ --- 531 11�i <br />