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Date mn 3/1/2018 3:52:45PM SAN JOA_jtN COUNTY ENVIRONMENTAL HEAL. — DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/1/2018 <br /> Record Selection Cnteriat Facility ID FA0022185 <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 OW0018450 New Owner ID <br /> Owner Name ORR, MICHELLE <br /> Owner DBA RICE POT MOVEMENT <br /> OwnerAddress 4534 FREEWAY CIR <br /> SACRAMENTO, CA 95841 <br /> Home Phone 916-439-6471 <br /> Work/Business Phone Not Specified <br /> Mailing Address 4534 FREEWAY CIR <br /> SACRAMENTO, CA 95841 <br /> Care of ORR, MICHELLE <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022185 <br /> Facility Name RICE POT MOVEMENT#71-165261 <br /> Location 1-7+�� <br /> -ST-OGK-T-9N-GA-95296-- 2G1 C-0 '15—. kl'Cl1 �IrAG � <br /> Phone 209-298-5416 xCOMM s,iprA—A-z � C� c, <br /> -?-o <br /> Address 4534 FREEWAY CIR <br /> SACRAMENTO, CA 95841 <br /> Care of ORR, MICHELLE <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 16904012 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name DURHAM, DION <br /> Title OPERATOR <br /> Day Phone 916-439-6471 <br /> Night Phone 916-439-6471 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0040450 NewAccount ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name RICE POT MOVEMENT#71-165261 (Circle One) <br /> Account Balance as of 3/1/2018: $0.00 <br /> (Circle One) <br /> Transfer to Adivellnai <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1635-MOBILE FOOD PREPARATION UNIT(MFPU) PRO538524 EE0008999-LEYNA HUYNH Active Y N A 1 0 <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSiEHD 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 ani 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 Chuck Number Received N <br /> EHD Staff: 00 AhMi 11Date i'>Account out: Date 13 / <br /> COMMENTS: I k Invoice#: <br /> COY b-� Cyrn m 1 ,SSU f`y <br />