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Date run 7/19/2018 10:29:12AP SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by <br /> Facility Information as of 7/19/2018 Pagel <br /> Record Selection Critane: Facility ID FA0023719 <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 OW0022052 New Owner ID <br /> Owner Name COFFMAN, LAURIE & LANCE <br /> Owner DBA VINE & BRANCHES CHRISTIAN BOOKSTOF <br /> OwnerAddress 2040 BISHOP WAY <br /> LODI, CA 95242 <br /> Home Phone 209-747-5510 <br /> Work/Business Phone Not Specified <br /> Mailing Address 2040 BISHOP WAY <br /> LODI, CA 95242 <br /> Care of COFFMAN, LAURIE <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0023719 <br /> Facility Name VINE & BRANCHES CHRISTIAN BOOKSTOF <br /> Location 110 W OAK ST <br /> LODI, CA 95240 <br /> Phone 209-334-3111 <br /> Mailing Address 110 W OAK ST <br /> LODI, CA 95240 <br /> Care of COFFMAN, LAURIE <br /> Location Code 02- LODI Alt Phone <br /> BOS District Fax <br /> APN EMail. <br /> EMERGENCY NOTIFICATION CONTACT INFORM/}'{fQ►{ EB O <br /> Contact Name COFFMAN, LAURIE <br /> Title <br /> Day Phone 209-334-3111 JUL 19 2018 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> ENVIONPRRMIT SERVICES <br /> Account ID AR0043890 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name VINE& BRANCHES CHRISTIAN BOOKSTORE (CirdeOne) <br /> Account Balance as of 7/19/2018: $0.00 <br /> (Cirde One) <br /> Program/Element and Description Transfer to Adivelinachve <br /> P Record ID Employee ID and Name Status New Owner'! Delete <br /> 1633-FOOD VEHICLE/CART(LTD FOOD PREP) PRO541394 EE0001084-STEPHANIE RAMIREZ Active Y N A I� D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ander projed specific,PHSIEHD hourly charges associated with this facility <br /> or adwily will be billed to the parry ideril as me ER on this for .TbIso certify that all operations will be performed in accortlance with all applicable Ordinance ho rly antlers associat and State andw <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 07/ /1, Z"l <br /> Program Records to be TRANSFERED: "$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Chao Number Receive�dt/�u11v <br /> EHD Staff: Date_/_/_ Account out: liY/ _Date_ i / Ar <br /> COMMENTS: <br /> Invoice#: <br />