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Date run 4/30/2018 8:54:06Afv SAN X UIN COUNTY ENVIRONMENTAL HEA DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 4/30/2018 <br /> Record Selection Criteria: Facility ID FA0020437 <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 OW0016784 New Owner ID <br /> Owner Name JUAREZ, RODOLFO CERDA <br /> Owner DBA JUAREZ PRODUCE <br /> OwnerAddress 1653 N ESCALON BELLOTA RD <br /> LINDEN, CA 95236 <br /> Home Phone 209-887-3406 <br /> Work/Business Phone 209-403-5586 <br /> Mailing Address 1653 N ESCALON BELLOTA RD <br /> LINDEN, CA 95236 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0020437 <br /> Facility Name JUAREZ PRODUCE #6E48746 <br /> Location 1653 N ESCALON BELLOTA RD <br /> LINDEN, CA 95236 <br /> Phone 209-887-3406 <br /> Mailing Address 1653 N ESCALON BELLOTA RD <br /> LINDEN, CA 95236 <br /> Care of RODOLFO JUAREZ <br /> Location Code 99 - UNINCORPORATED A Alt Phone <br /> BOS District 004 -WINN, CHARLES Fax <br /> APN 09314007 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name RODOLFO JUAREZ <br /> Title <br /> Day Phone 209-887-3406 <br /> Night Phone 209-403-5586 Cell <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0036497 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name JUAREZ PRODUCE #6E48746 (Circle One) <br /> Account Balance as of 4/30/2018: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inacive <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1636-'�ITD FOOD VEHICLE(PRODUCE/WHOLE FISH) PR0535444 EE0008999-LEYNA HUYNH Inactive 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 andtor <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 -!5-- <br /> COMMENTS: <br /> COMMENTS: <br /> Invoice#: _/ <br />