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Daterun ;yt/1712020 1:59:20PK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by M OZUNA Facility Information as of 6/17/2020 Pagel <br /> Record Selection Criteria: Facility ID FA0025374 <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 OW0024042 New Owner ID <br /> Owner Name GUPTA, MAMTA <br /> Owner DBA MASALA BLEND <br /> OwnerAddress 2127 SADDLEBROOK ST <br /> STOCKTON, CA 95209 <br /> Work/Business Phone Not Specified <br /> Alternative Phone 209-406-6523 <br /> Mailing Address 2127 SADDLEBROOK ST <br /> STOCKTON, CA 95209 <br /> Care of GUPTA, MAMTA <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0025374 <br /> Facility Name MASALA BLEND <br /> Location 2127 SADDLEBROOK ST <br /> STOCKTON, CA 95209 <br /> Phone 209-406-6523 <br /> Mailing Address 2127 SADDLEBROOK ST <br /> STOCKTON, CA 95209 <br /> Care of GUPTA, MAMTA <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name GUPTA, MAMTA <br /> Title <br /> Day Phone 209-406-6523 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0047796 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name MASALA BLEND (Circle One) <br /> Account Balance as of 6/17/2020: $155.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Progrpm/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> CLASS prCOTTAGE FOOD-DIRECT SALES PR0544635 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: �i L A s 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 b <br /> EHD Staff: Date / / Account out: Date_�/ / ­70 <br /> COMMENTS: <br /> IrIV01Ce#: <br /> '.Ste__ A �a4j <br /> ?q ek <br /> ,� <br />