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,Date run . 8/24/2022 1 08:14Ph SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by M OZUNA Pagel <br />Facility Information as of 8/24/2022 <br />Record Selection Criteria: Facility ID FA0026631 <br />OWNER FILE INFORMATION Number of facilities for this owner <br />Owner ID <br />OW0025280 <br />Owner Name <br />SYSAY, SOUBANH JOHN <br />Owner DBA <br />OLIVE'S <br />OwnerAddress <br />2934 MONTICELLO DR <br />Phone <br />STOCKTON, CA 95209 <br />Work/Business Phone <br />Not Specified <br />Alternative Phone <br />209-298-6981 <br />Mailing Address <br />2934 MONTICELLO DR <br />STOCKTON, CA 95209 <br />Care of <br />SYSAY, SOUBANH JOHN <br />FACILITY FILE INFORMATION APN 04532005 <br />Facility ID / CERS ID <br />FA0026631 <br />Facility Name <br />OLIVE'S #4SZ2635 <br />Location <br />620 S SACRAMENTO ST <br />LODI, CA 95240 <br />Phone <br />209-224-8334 xCOMM <br />Mailing Address <br />2934 MONTICELLO DR <br />STOCKTON, CA 95209 <br />Care of <br />SYSAY, SOUBANH JOHN <br />1 <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name SYSAY, SOUBANH JOHN <br />Title PAYMENT <br />Day Phone 209-224-8334 xCOMM RECEIVED <br />Night Phone 209-298-6981 Cell <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0050730 <br />Mail Invoices to Facility <br />Account Name OLIVE'S #4SZ2635 <br />Email invoice to (up to 2 emails) djblackolive@yahoo.com <br />Email permit to (up to 2 smalls) djblackolive@yahoo.com <br />Account Balance as of 8/24/2022: $0.00 <br />AUG 2 4 2022 <br />Make changeslcorrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Program/Element and DescriptionRecord ID Employee ID and Name Status Transfere ActiD leetaedve <br />New Owner? <br />1635 - MOBILE FOOD PREPARATION UNIT (MFPU) PRO546997 EE0001084 -STEPHANIE RAMIREZ Active Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENTS I, the undersigned owner, operator or agent ofsame, acknowledge that all site, ander project specific, PHSrEHO hourly charges associated with this facility <br />or activity will be billed to the party identified as the OWNER on this form. I also cerffy that all operations will be performed in accordance with all applicable Ordinance Codes anclor Standards and State ai <br />Federal Laws. <br />APPLICANTS SIGNATURE: <br />Program Records to be TRANSFEREt <br />Water System to be TRAN FED: _ <br />Payment Type Check I <br />EHD Staff: <br />COMMENTS <br />Date v / _ <br />25,0 Amount PaidDate_! / <br />Amount Pai _L Date / 2 /.Z2— <br />1 T25h /IZJ / - Received by <br />Date_/ / Account out: elClE Date g /UL <br />Invoice 0: 3 <br />