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Date run 12/4/2018 4:05:16PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/4/2018 <br /> Record Selection Criteria: Facility ID FA0022042 <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 OW0018150 New Owner ID <br /> Owner Name CHAPPELL, CYNTHIA <br /> Owner DBA SWEET CINDYS GOODIES GALORE <br /> OwnerAddress 140 S AVENA AVE <br /> LODI, CA 95240 <br /> Home Phone 209-365-3677 <br /> Work/Business Phone Not Specified <br /> Mailing Address 140 SAVE NAAVE <br /> LODI, CA 95240 <br /> Care of CHAPPELL, CYNTHIA <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022042 <br /> Facility Name SWEET CINDYS GOODIES GALORE <br /> Location 140 S AVENAAVE <br /> LODI, CA 95240 <br /> Phone 209-365-3677 <br /> Mailing Address 140 S AVENA AVE <br /> LODI, CA 95240 <br /> Care of CHAPPELL, CYNTHIA <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 03718009 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name CHAPPELL, CYNTHIA <br /> Title <br /> Day Phone 209-365-3677 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0040205 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name SWEET CINDYS GOODIES GALORE (Circle One) <br /> Account Balance as of 12/4/2018: $-155.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1608-CLASS A COTTAGE FOOD-DIRECT SALES PR0538160 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,and/or project specific,PHS/EHD 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 and/or Standards and State and/or <br /> Federal Laws. <br /> APPLICANT'S 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 Staff: DateAccount out: Date--,t2,=/ 7 / <br /> COMMENTS: <br /> Invoice#: <br /> cha'T Ac C/ <br />