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Date him 6/22/2021 9:51:00AN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/22/2021 <br /> Record Selection Criteria: Facility ID FA0026314 <br /> Make changes/corrections in RED Ink. Z <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 OW0024954 New Owner ID <br /> Owner Name GOMEZ, MARIA TERESA <br /> owner DBA MY MAMAS TACOS <br /> OwnerAddress 4719 QUAIL LAKES DR G278 <br /> STOCKTON, CA 95207 <br /> Work/Business Phone Not Specified <br /> Alternative Phone 209-915-5067 <br /> Mailing Address 4719 QUAIL LAKES DR G278 <br /> STOCKTON, CA 95207 <br /> Care of GOMEZ, MARIA TERESA <br /> FACILITY FILE INFORMATION APN 04532005 <br /> Facility ID/CERS ID FA0026314 U C LVS—) 131 <br /> Facility Name MY MAMAS TACOS#ftk22z"`34 <br /> Location 1'I 1-1 S UNI oel <br /> I nnl 6sFirwf�.1 (/�, �1CiZQ0 <br /> Phone 209-224-8334 xCOMM <br /> Mailing Address 4719 QUAIL LAKES DR G278 <br /> STOCKTON, CA 95207 <br /> Care of GOMEZ, MARIA TERESA <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name GOMEZ, MARIA TERESA <br /> Title <br /> Day Phone 209-224-8334 xCOMM <br /> Night Phone 209-915-5067 Cell <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0049998 New Account ID: <br /> Mail Invoices to Facility LITS-713,9 Mail Invoices to: Owner / Facility / Account <br /> Account Name MY MAMAS TACOS#AtY22Z34 (Circle One) <br /> Email invoice to(up to 2 emails) <br /> Email permit to(up to 2 emails) <br /> Account Balance as of 6/22/2021: $0.00 <br /> (Circle One) <br /> Proram/Elemenl and Descri tion K Transfer to ActivenracNe <br /> Program/Element D Record ID Employee ID and Name r • Status New Owner? Delete <br /> 1635-MOBILE FOOD PREPARATION UNIT( FPU) PRO546432 EE0001084- Active Y N A I D <br /> BILLING and COMPLIANCEACKNOWLEDGEMENT: I,t undersign owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed(a the party itlenlisatl as the 0 on this I also certify that all operations will be performed in accordance with all applicable Ordinance Codes and'ar Standards and State and'or <br /> Federal laws. rr^^ <br /> APPLICANT'S SIGNATURE: Date W /ZZ / 21 <br /> Program Records to be TRANSFE '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date / I <br /> Payment Type Check Number Received ) <br /> EHD Staff: � 2 Date_S�! /� Account out: Date / d/ <br /> COMMENTS: <br /> Invoice#: <br /> G3CEcC[1MD <br /> JUN 2 2 2021 <br /> ENVIRONMENTAL HEALTH <br /> PERMIT/SERVICES <br />