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Date am • 3/24,2022 8:59:18AK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report #5021 <br />Run by Pagel <br />Facility Information as of 3/24/2022 <br />Record Selection Criteria: Facility ID FA0026414 <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 OW0025062 New Owner ID <br />Owner Name SANTOS, BYRON <br />Owner DBA KAYLEE'S SWEET BOTANITAS <br />OwnerAddress 6 S CARROLL AVE <br />STOCKTON, CA 95215 <br />Work/Business Phone Not Specified <br />Alternative Phone 209-649-8993 <br />Mailing Address �S.£IILrt7{VE 3 // M C ra'uf t(✓t= <br />STOCKTON, CA 95215S% p cam: <br />Care of SANTOS, BYRON <br />FACILITY FILE INFORMATION APN 16904012 <br />Facility ID / CERS ID FA0026414 <br />Facility Name KAYLEE'S SWEET BOTANITAS #4SX8143 <br />Location 1717 S UNION ST <br />STOCKTON, CA 95206 <br />Phone 209-298-5416 xCOMM <br />Mailing Address "G44ReL±-AV1`E .2 2 3 // M&-- c.,-r ✓ L' <br />STOCKTON, CA 95215 KTov <br />Care of SANTOS, BYRON <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name SANTOS, BYRON p/��({�����y/��-� <br />Title �✓E \'/ 1� n <br />Day Phone 209-298-5416 xC <br />Night Phone 209-649-8993 Cell MAR 24 20 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0050243 ENVIRONMENTAL HEALTH <br />New Account ID: <br />Mail lnvoicesto Facility pRS <br />Mail Invoices to: Owner / Facility / Account <br />Account Name KAYLEE'S SWEET BOTANITAS #4SX8143 (Circle One) <br />Email invoice to (up to 2 entrails) kayleebyronl@gmail.com <br />Email permit to (up to 2 emails) kayleebyronl@gmail.com <br />Account Balance as of 3/24/2022: $0.00 <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner/ Delete <br />1633 - FOOD VEHICLE/CART (LTD FOOD PREP) PRO546568 EE0004589 - KADEANNE LINHARES Inactive Y N A I D <br />1635 - MOBILE FOOD PREPARATION UNIT (MFPO PR0547047 EE0004589 - KADEANNE LINHARES Active Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, me undersigned owner, operator or agent of same, acknowledge that all site, andror project specific, PHSEHD hourly charges associated with this facility <br />or activity will be billed to the party identified as Me OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andror <br />Federal Laws. r-2 <br />APPLICANT'S SIGNATURE: / 3 i/ 1 <br />G ,Ti l Date 11 y l Z Z <br />Program Records to be TRANSFERED: ' $25.00 = Amount Paid Date // <br />Water System to be TRANSFERED: Amount Paid Date / / <br />Payment Type Check Number Received <br />EHD Stag: Date // Account out: Date <br />COMMENTS: <br />Invoice #: <br />