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4/25/2024 11:58:15Ar SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />Facility Information as of 4/25/2024 <br />Record Selection Criteria:Facility ID FA0026702 <br />Number of facilities for this owner:1 <br />Not Specified <br />Mailing Address <br />Care of MEDINA, DEZIREE <br />APNFACILITY FILE INFORMATION <br />Mailing Address <br />Care of MEDINA, DEZIREE <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />StatusRecord ID <br />DAActivePR0547088 <br />//DateAPPLICANT'S SIGNATURE: <br />* S25.00 = <br />/IDate <br />Invoice #: <br />5^ <br />Date run <br />Run by <br />Work/Business Phone <br />Alternative Phone <br />SSN / Fed Tax ID : <br />New Owner ID : <br />Report #5021 <br />Paget <br />(Circle One) <br />Active/lnactve <br />Delete <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />Employee ID and Name <br />EE0009836 - SANDIP SINGH <br />Contact Name BLUBAUGH, CARRIE <br />Title <br />Day Phone <br />Night Phone <br />O' activitywill befbilledTc/the ^rtV.dent^ as t^ form I also'certify that all operations will be performed in accordance with all applicable Ordinance Codes anchor Standards and State and/or <br />Federal Laws <br />_____ Date H <br />Account ID AR0050864 <br />Mail invoices to Account <br />Account Name AESTHETICS LASH INK <br />Email invoice to (up to 2 emails) <br />Email permit to (up to 2 emails) <br />Account Balance as of 4/25/2024: $308.00 <br />Facility ID / CERS ID FA0026702 <br />Facility Name AESTHETICS LASH INK (MEDINA, DEZIREE <br />Location 1955 LUCILLE AVE <br />STOCKTON, CA 95209 <br />Phone 209-888-5738 <br />OWNER FILE INFORMATION <br />Owner ID OW0025353 <br />Owner Name MEDINA, DEZIREE <br />Owner DBA AESTHETICS LASH INK <br />Owner Address <br />Amount Paid Date _ <br />_ Amount Paid Date <br />Received by <br />Account out: <br />New Account ID: Mail Invoices to: Owner / Facility / Account(Circle One) <br />/ <br />/ <br />./ <br />/ <br />Transfer to <br />New Owner? <br />Y N <br />135 124 <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: ( <br />COMMENTS: ' <br />IuaC-HVATL PEPKtI • <br />Program/Element and Description <br />4110 - BODY ART PRACTITIONER REGISTRATION <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT I, the undersigned owner, operator or agent of same, acknowledge that all site, and/or project specific, PHS/EHD hourly charges associated with this facility