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Date run 8/22/2017 12:43:27PI SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report 95021 <br /> Pagel <br /> Run by <br /> Facility Information as of 8/22/2017 <br /> Record Selection Criteria: Facility ID FA0023896 <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 OW0022330 New Owner ID : <br /> Owner Name FRERICHS,ANDREW <br /> Owner DBA AJ FRERICHS ENTERPRISE <br /> Owner Address PO BOX 110 <br /> TRACY, CA 95378 <br /> Home Phone 209-627-8116 <br /> Work/Business Phone Not Specified <br /> Mailing Address PO BOX 110 <br /> TRACY, CA 95378 <br /> Care of FRERICHS,ANDREW <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0023896 <br /> Facility Name AJ FRERICHS ENTERPRISE <br /> Location 28323 S MAC ARTHUR RD <br /> TRACY, CA 95304 <br /> Phone 209-627-8116 <br /> Mailing Address PO BOX 110 <br /> TRACY, CA 95378 <br /> Care of FRERICHS,ANDREW <br /> Location Code 03-TRACY Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name FRERICHS,ANDREW <br /> Title <br /> Day Phone 209-627-8116 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0044323 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility / Account <br /> Account Name AJ FRERICHS ENTERPRISE (Circle One) <br /> Account Balance as of 8/22/2017: $0.00 <br /> (Circle One) <br /> Transfer to ActiveAnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1680-COMMISSARY(MFPU&FOOD PREP) PR0541691 EE0001420-MELISSA NISSIM Active,I Y N A to� D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENTS I,the undersigned owner,operator or agent of same,acknowledge that all site,andlor project specific,PHSfEHD hourly charges associated wil 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 andfor Standards and State ancilor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I ! <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date 1 I <br /> Water System to be TRANSFERED: Amount Paid Date / ! <br /> Payment Type Check Number Received <br /> EHD Staff:'Zu A j Date 1 !f Account out: Date_�l 2.2— l Z7 <br /> COMMENTS: Invoice#: <br /> hGH �� v u t? rU y3t! �� jOyt <br /> p� <br /> �� Cr � � ► nq Gr S� �� ��r own nr <br />