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Date run '' 313!2016 3:59:59PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 3/3/2016 <br /> Record Selection Criteria: Facility ID FA0022347 <br /> Make changeslcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN 1 Fed Tax ID <br /> Owner ID OW0018651 New Owner ID <br /> Owner Name KATZAKIAN, CYNDI <br /> Owner DBA <br /> Owner Address 735 N FINE RD <br /> LINDEN, CA <br /> Home Phone 209-482-7846 <br /> Work/Business Phone 209-482-7846 <br /> Mailing Address PO BOX 1230 <br /> LINDEN, CA 95236 <br /> Care of KATZAKIAN, CYNDI <br /> FACILITY FILE INFORMATION <br /> Facility ID!CERS ID FA0022347 <br /> Facility Name BAM TREATS <br /> Location 735 N FINE RD <br /> LINDEN, CA 95236 <br /> Phone 209-482-7846 <br /> Mailing Address PO BOX 1230 <br /> LINDEN, CA 95236 <br /> Care of KATZAKIAN, CYNDI <br /> Location Code 99- UNINCORPORATED P Alt Phone <br /> Bos District 004 -WINN, CHARLES Fax <br /> APN 10529001 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name CYNDI KATZAKIAN <br /> Title <br /> Day Phone 209-482-7846 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0040873 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility / Account <br /> Account Name BAM TREATS (Circle One) <br /> Account Balance as of 31312016: $0.00 <br /> (Circle One) <br /> Transfer to Activeflnactve <br /> ProgramlElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1609-CLASS B COTTAGE FOOD-INDIRECT SALES PR0538896 EE0008999-LEYNA HUYNH Active Y N A 1 D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andfor project specific,PHSIEHD 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 andfor Standards and State andfor <br /> Federal Laws. <br /> APPLICANT'S SIGNATURE: Date I I <br /> Program Records to be TRANSFERED: *$25.00= Amount Paid Date 1 ! <br /> Water System to be TRANSFERED: Amount Paid Date 1 ! <br /> Payment Type -____,,qhecV Number Receiv/ed/� <br /> EHD Staff: _ T _ Date ! 2 ! Account out: [.�� Date .3 17 114, <br /> COMMENTS: <br /> Invoice#; <br /> 14pb <br />