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Date run 12/22/2015 1:14:27P SAN JI UIN COUNTY ENVIRONMENTAL HEi I DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 12/22/2015 <br /> Record Selection Criteria: Facility ID FA0021289 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) ZZ S <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0017549 New Owner ID <br /> Owner Name HA, TUAN M <br /> Owner DBA H & H CHINESE FOOD <br /> Owner Address 9122 BLUEGRASS DR <br /> STOCKTON, CA 95210 <br /> Home Phone 209-817-2244 2(39 Qi r7— YI66 <br /> Work/Business Phone Not Specified <br /> Mailing Address 9122 BLUEGRASS DR <br /> STOCKTON, CA 95210 <br /> Care of HA, TUAN M <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0021289 <br /> Facility Name H & H CHINESE FOOD#8A17689 <br /> Location 2440 S AIRPORT WAY <br /> STOCKTON, CA 95206 <br /> Phone 209-466-9000 XCOMMISSARY <br /> Mailing Address 9122 BLUEGRASS DR <br /> STOCKTON, CA 95210 <br /> Care of HA, TUAN M <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA, CARLOS Fax <br /> APN 16913327 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name HA, TUAN M o D <br /> Title <br /> Day Phone 209-817-2244 Cell (ZO,7 /?`7 -`i f,!_,f C 6GL <br /> Night Phone L,-C 2 2 2016 ( <br /> ACCOUNTS RECEIVABLE FILE INFORMATION ENVIRONMENT HEALTH <br /> Account ID AR0038567 PERMIT/SERVICES New Account-9: <br /> Mail Invoices to Facility Mail Invoices to: Owner l/ Facility / Account <br /> Account Name H & H CHINESE FOOD#8A17689 (Circle One) <br /> Account Balance as of 12/22/2015: $203.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1635-MOBILE FOOD PREPARATION UNIT(MFPU) PR0537102 EE0004589-KADEANNE LINHARES Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,anclVor 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 andror <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: r —A—, Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type ck Number Received b <br /> � <br /> EHD Staff: Date��/�'�/ Account out: Date�/ / /S-- <br /> COMMENTS: <br /> Invoice#: <br />