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Date ren 1/23/2018 1:46:23PR SAN JOA. N COUNTY ENVIRONMENTAL HEAL' DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 1/23/2018 <br /> Record Selection Criteria: Facility ID FA0021790 <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 OW0020177 New Owner ID <br /> Owner Name MENDOZA, ANA <br /> Owner DBA <br /> Owner Address 1804 DECARLI ST <br /> STOCKTON, CA 95206 <br /> Home Phone 209-242-3998 <br /> Work/Business Phone 209-464-4570 <br /> Mailing Address 1804 DECARLI ST <br /> STOCKTON, CA 95206 <br /> care of MENDOZA, AVA <br /> FACILITY FILE INFORMATION <br /> Facility ID I CERS ID FA0021790 <br /> Facility Name FRUTA FRESCA LOS ALEGRES#4GZ7437 <br /> Location 2900 E HARDING WAY <br /> STOCKTON, CA 95205 <br /> Phone 209-464-4570 <br /> Mailing Address 1804 DECARLI ST <br /> STOCKTON. CA 95206 <br /> Care of MENDOZA. ANA <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 14310020 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> DContact Name ANA MENDOZA �(� '� <br /> �G <br /> Title n <br /> Day Phone 209-464-4570 w <br /> Night Phone 209-242-3998 SAN 2 3 2016 <br /> ACCOUNTS RECAccouBLDFILE <br /> INFORMATION <br /> AR0039622ENUP RM,T S ARV CE LTH NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name FRUTA FRESCA LOS ALEGRES#4GZ7437 (Circle One) <br /> Account Balance as of 1/23/2018: $169.00 <br /> (Circle One) <br /> Transfer to Activehnactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? f^Delelete <br /> 1633-FOOD VEHICLE/CART(LTD FOOD PREP) PRO534981 EE0008999-LEYNA HUYNH Active Y N A / / D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project specific,PIS1EI-D 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 andor Standards and State andor <br /> Federal Laws. //I/,n /SII <br /> CI APPLICANT'S SIGNATURE: /�"y"= ,/l"r��"` P-� ilQ� !�° 4 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 y <br /> EHD Staff: Date I /-A3 /10 Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />