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Date run 4/27/2018 9:08:62AN SAN JOA N COUNTY ENVIRONMENTAL HEAL' )EPARTMENT Report#5021 <br /> Run by MOZUNA -- Pagel <br /> Facility Information as of 4/27/2018 <br /> Record Selection Criteria: Facility ID FA0023469 <br /> Make changesicorrections 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 OW0021712 New Owner ID <br /> Owner Name SOTELO, MARCO <br /> Owner DBA RINCON TAXQUENO <br /> Owner Address 7926 HANEY LN <br /> STOCKTON, CA 95212 <br /> Home Phone 650-279-4078 <br /> Work/Business Phone Not Specified <br /> Mailing Address 7926 HANEY LN <br /> STOCKTON, CA 95212 <br /> Care of SOTELO, MARCO <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0023469 <br /> Facility Name RINCON TAXQUENO#4PN2938 <br /> Location 2900 E HARDING <br /> STOCKTON, CA 95205 <br /> Phone 209464-4570 <br /> Mailing Address 7926 HANEY LN <br /> STOCKTON, CA 95212 <br /> Care of SOTELO, MARCO <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002 - MILLER, KATHERINE Fax <br /> APN 14310020 p T Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATIOrPA-fME� <br /> Contact Name SOTELO, MARCO RECEIVE <br /> Title 2oI8 <br /> Day Phone 209464-4570 APR Z <br /> Night Phone 650-279-4078 SAN JOAQUIN COU14TY <br /> NPARTMEN <br /> ACCOUNTS RECEIVABLE FILE INFORMATION EEAt�TMpOEMENTAL T <br /> Fi <br /> Account ID AR0043264 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name RINCONTAXQUENO#4PN2938 (Circle One) <br /> Account Balance as of 4/27/2018: $0.00 <br /> (Circle One) <br /> Transfer to Activelinactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Oymer Delete <br /> 1635-MOBILE FOOD PREPARATION UNIT(MFPU) PR0541000 EE0008999-LEYNA HUYNH Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andror project specific,PHSIEHD hourly charges associated with thisfacility <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 accordancewith all applicable Ordinance Codes andror Standards and State andlor <br /> Federal Laws. //p1 '� <br /> APPLICANT'S SIGNATURE ��� `�` Date d LV l�l 2-od, it <br /> Program Records to be TRA NSFE D: '$25.00= Amount Paid Date <br /> Water System to be J¢tAN ERED: Amount Date <br /> Payment Type - (�. Check Number IIITTT Received b k <br /> EHD Staff: Date / / Account out: 6atel 27 <br /> COMMENTS: <br /> Invoice#: 2a78(v-7 <br />