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Date run 9/23/2004 1:19:47PN SAN JC JUIN COUNTY ENVIRONMENTAL HEAL'T'H DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 9/23/2004 <br /> Record Selection Criteria: Facility ID FA0015599 <br /> Make changes/corrections in RED ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION <br /> Owner ID OW0012546 New Owner ID <br /> Owner Name SCHENONE, ERNIE P JR <br /> Owner DBA CHOCOHOLICS DIVINE DESSERTS <br /> Owner Address 4860 GRANADA CT <br /> LINDEN, CA 95236 <br /> Home Phone 209-759-3340 <br /> Work/Business Phone Not Specified <br /> Mailing Address 4860 GRANADA CT <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0015599 <br /> Facility Name CHOCOHOLICS DIVINE DESSERTS <br /> Location 18819 E HWY 88 <br /> CLEMENTS, CA 95227 <br /> Phone 209-759-3340 <br /> Mailing Address PO BOX 730 <br /> CLEMENTS, CA 95227 <br /> Care of ERNIE P SCHENONE JR <br /> Location Code 98 - OUT OF COUNTY APN: <br /> BOS District 000 - Unknown SIC Code: <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0026931 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name CHOCOHOLICS DIVINE DESSERTS (Circle One) <br /> Account Balance as of 9/23/2004: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1620-RETAIL MKT<25 SO FT(INCIDENTAL FOOEPRO523110 EE0003027-MINH NGUYEN 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 <br /> facility 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 Ordinace Codes and/or Standards and <br /> State and/or Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date <br /> Water System to be TRANSFERED: *$155.00= Amount Paid Date / ! <br /> Payment Type Check Number Received by <br /> REHS: Date / / Account out: Date <br /> COMMENTS: <br /> \\r)b.-phSP I-nt\arms\envies ns\reports\5021.rpt <br />