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Date run 9/9/2015 10:44:27AM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> Report#5021 <br /> Pagel <br /> Ron by Facility Information as of 9/9/2015 <br /> Record Selection Criteria: Facility ID FA0022482 <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 OW0019942 New Owner ID <br /> Owner Name DOLLAR, ERICA N <br /> Owner DBA BAKLAVA CITY <br /> Owner Address 801 ATHERTON DR#226 <br /> MANTECA, CA 95337 <br /> Home Phone 209-482-4399 <br /> Work/Business Phone Not Specified <br /> Mailing Address <br /> MANTECW—C—A 9 (`1ct�r.1 2 CG Csw <br /> care of DOLLAR, ERICA N <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0022482 <br /> Facility Name BAKLAVA CITY <br /> Location 801 ATHERTON DR#226 <br /> MANTECA, CA 95337 <br /> Phone 209-482-4399 +� _ t� <br /> Mailing Address L) V � t 0 rJ 1 nj K <br /> 7 wJAZCc. CA ct S <br /> Care of DOLLAR, ERICA N <br /> Location Code 04- MANTECA Alt Phone <br /> BOS District 005 - ELLIOTT, BOB Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name DOLLAR, ERICA N <br /> Title <br /> Day Phone 209-482-4399 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0041152 New Account ID: <br /> Maillnvoicesto Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name BAKLAVA CITY (Circle one) <br /> Account Balance as of 9/9/2015: $125.00 <br /> (Circle One) <br /> Transfer to Achve/Inacive <br /> Program/Element and Description Record ID Employee 10 and Name Status New Owners Delete <br /> 1608-CLASS A COTTAGE FOOD-DIRECT SALES PR0539318 EE0004589-KADEANNE LINHARES Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,Ne undersigned owner.operator or agent of same,acknowledge that all site,andor Project specific PHSEHO hourly charges associated with this facility <br /> or activity will be billed to the party Identried as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State ands <br /> Federel Laws. <br /> APPLICANTS SIGNATURE: Date / / <br /> Program Records to be TRANSFERED: •$25.00= Amount Paid Date / I <br /> Water System to be TRANSFERED: Amount Paid Date <br /> Payment Type Check Number Received by <br /> EHD Staff: Date / / Account out: Date '5 / // S <br /> COMMENTS: <br /> Invoice#: 1 <br />