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Date run, 6/14,42022 4:20:15PN SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 6/14/2022 <br /> Record Selection Criteria: Facility ID FA0026614 <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 OW0025262 New Owner ID <br /> Owner Name MADRIZ,AMANDA <br /> Owner DBA DREAMSCAPE BROWS <br /> OwnerAddress 1319 CEDAR AVE <br /> ATWATER, CA 95301 <br /> Work/Business Phone Not Specified <br /> Alternative Phone 209-445-1460 <br /> Mailing Address 1319 CEDAR AVE <br /> ATWATER, CA 95301 <br /> Care of MADRIZ,AMANDA <br /> FACILITY FILE INFORMATION APN <br /> Facility ID/CERS ID FA0026614 <br /> Facility Name DREAMSCAPE BROWS (MADRIZ,AMANDA <br /> Location 3422 W HAMMER LN UNIT F <br /> STOCKTON, CA 95219 <br /> Phone 916-873-6703 <br /> Mailing Address 1319 CEDAR AVE <br /> ATWATER, CA 95301 <br /> Care of MADRIZ,AMANDA <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name MADRIZ, MICHELLE <br /> Title <br /> Day Phone 209-743-9820 <br /> Night Phone 209-743-9820 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0050665 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name DREAMSCAPE BROWS (Circle One) <br /> Email invoice to(up to 2 emails) <br /> Email permit to(up to 2 emails) <br /> Account Balance as of 6/14/2022: $152.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 4110-BODY ART PRACTITIONER REGISTRATION PRO546971 EE0009853-PINNE CHAO Active Y N A L/ D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: 1,the undersigned owner,operator or agent of same,acknowledge that all site,and/or 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 and/or <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date <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 b <br /> EHD Staff: Q• cm Date Account out: Date /zo �— <br /> COMMENTS: <br /> Invoice#: <br /> IWAc'I1V1'IE ��� I°�IR- EM1►t. <br />