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Date run 10/31/2018 4:53:22P SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by M OZUNA Pagel <br /> Facility Information as of 10/31/2018 <br /> Record Selection Criteria: Facility ID FA0023168 <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 SSNIFed Tax ID : <br /> Owner ID OW0021297 New Owner ID <br /> Owner Name TELLY, NANCI A <br /> Owner DBA NBT- NOTHING BUT TREATS <br /> Owner Address 912 JASMINE HOLLOW DR Odr /moi <br /> MANTECA, CA 95337 <br /> Home Phone 209-823-2233 <br /> Work/Business Phone Not Specified <br /> Mailing Address 912 JASMINE HOLLOW DR 3 y biL' <br /> MANTECA, CA 95337 <br /> Care of TELLY, NANCI A <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0023168 <br /> Facility Name NET- NOTHING BUT TREATS <br /> Location 912 JASMINE HOLLOW DR /3 -2 IV A L <br /> MANTECA, CA 95337 <br /> Phone 209-823-2233 <br /> Mailing Address 912 JASMINE HOLLOW DR <br /> MANTECA, CA 95337 <br /> Care of TELLY, NANCI A <br /> Location Code 04-MANTECA Alt Phone <br /> BOB District Fax <br /> APN EMail <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name TELLY, NANCI A <br /> Title <br /> Day Phone 209-823-2233 <br /> Night Phone <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0042581 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name NBT- NOTHING BUT TREATS (Circle One) <br /> Account Balance as of 10/31/2018: $0.00 <br /> (circle One) <br /> Transfer to ActiveAnactve <br /> ProgramlElemenl and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1608-CLASS A COTTAGE FOOD-DIRECT SALES PRO540510 EE0008987-SCOTT SANGALANG Active Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,Ne undersigned owner,operator or agent of same,acknowledge that all site,andfor protect specific,PHStEHD hourly charges associated with this facility <br /> or activity will be billed to the parry 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 andbr <br /> Federal Laws. << I <br /> APPLICANTS SIGNATURE: c,ems_ {{` ,� 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 by <br /> EHD Staff. Date / / Account out: Date <br /> COMMENTS: <br /> Invoice#: <br />