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Date run 11/30/2015 1:45:50F SAN JO. IN COUNTY ENVIRONMENTAL HEAL DEPARTMENT Report#5021 <br /> Run by , Pagel <br /> • . Facility Information as of 11/30/2015 <br /> Record Selection Criteria: Facility ID FA0022685 <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 OW0020357 New Owner ID <br /> Owner Name LLAMAS, FRANCISCO <br /> Owner DBA <br /> Owner Address 2846 RENEE MARY WAY <br /> STOCKTON, CA 95205 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address AY <br /> STOCKT@WO 95205 <br /> Care of LLAMAS, FRANCISCO <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022685 <br /> Facility Name EL GRULLITO#5E71359 & 8T81062 <br /> Location 730 S CALIFORNIA ST <br /> STOCKTON, CA 95203 <br /> Phone 209-464-9707 <br /> Mailing Address Y <br /> S 95205 <br /> Care of LLAMAS, FRANCISCO <br /> Location Code 01 - STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 14723003 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name FRANCISCO LLAMAS <br /> Title <br /> Day Phone 209-464-9707 XCOMMI <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0041538 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name EL GRULLITO#5E71359 & 8T81062 (Circle One) <br /> Account Balance as of 11/30/2015: $536.00 <br /> (Circle One) <br /> Transferto Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1635-MOBILE FOOD PREPARATION UNIT(MFPU) PR0535478 EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> 1635-MOBILE FOOD PREPARATION UNIT(MFPU) PR0536513 EED003361 -MARIBEL FLOHRSCHUTZ 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 b <br /> EHD Staff: Date / / Account out: Date 7Z l�l I <br /> COMMENTS: <br /> Invoice#: <br />