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Date mn 9/19/2014 83137AN SAN J( JIN COUNTY ENVIRONMENTAL HEA , -A DEPARTMENT Report#5021 <br /> 1++ <br /> R-01 Pagel <br /> Facility Information as of 9/19/2014 <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: 3 SSN/Fed Tax ID <br /> Owner ID OW0015370 New Ow er ID <br /> Owner Name tC t•( ,Z vltNdoZ <br /> Owner DBA FRUTA FRESCA LOS ALEGRES cv Z� rcSC a L-os le rC-'S- <br /> Owner 1-34 <br /> Address ^„F Pan -5'17 <br /> CA 95215S fec kF6 N•f fit• X15 3-6(0- <br /> Home Phone 7�- cpa C2-o41 IE-i4-Sol T3 <br /> Work/Business Phone Not Specified <br /> Mailing Address Salle <br /> Care of,FSPIN07A-FRIAS, ENRIQ_ UE rVN&'�Q,�-z a. <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021790 <br /> Facility Name FRUTA FRESCA LOS ALEGRES#41327437 <br /> Location 2900 E HARDING WAY <br /> STOCKTON, CA 95205 <br /> Phone 209-464-4570 xCOMMISSARY <br /> Mailing Address <br /> Care of - ` OG�II pN� eQ• J��v <br /> Location Code 99 - UNINCORPORATED P Alt Phone <br /> BOS District 002 - RUHSTALLER, LARRY Fax <br /> APN 14310020 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name roPl nen FR nS ENRIQ t� CCGJ-- Z' /\/tA-)C,p•'Za^ <br /> Title <br /> " � PAYMEN n caoC1 A 1- 3 11 11 W <br /> Day Phone 209464-9707 xCOMMI RECEIVEn <br /> Night Phone 209 43G ;275--Sei� <br /> ACCOUNTS RECEIVABLE FILE INFORMATION SEP 1 - 2014 <br /> Account ID AR0039622 SAN JOAQUIN COUNTY New Account ID: <br /> Mail Invoices to ENVIROMENTMENT <br /> Facility HEALTH DEPARTMMail Invoices to: Owner / Facility / Account <br /> Account Name .FRUTA FRESCA LOS ALEGRES#4627437 (Circle One) <br /> Account Balance as of 9/19/2014: $0.00 <br /> (Circle One) <br /> Tranderto Active/Inadve <br /> �///pQpQpQr"""o"%g���ygfff/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> to soJ 3MOBILE FOOD PREPARATION UNIT lPR0534981 EE0008999-LEYNA HUYNH Inactivi Z51 9A 1 D <br /> /BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHS/EHD hourly charges associated with this facility <br /> or activity will be billed to the Party identified as the OWNER an this form. I also minify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and Slate andor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: IU-4e% Date G <br /> / <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date /-LI-/ t L4 <br /> Water system to beNSFERj_D: Amount Paid Date / / <br /> Payment Type LL-NN��----Check Number Recel <br /> REHS: Date J7 / 5 / Account out: Date / / 1y <br /> COMMENTS: <br />