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Date run 4/1/2019 4:07:29PM SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 4/1/2019 <br /> Record Selection Criteria: Facility ID FA0024540 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) —3 <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0023123 New Owner ID <br /> Owner Name ROGERS, ELWANDA <br /> Owner DBA TEELICIOUS TREATS CUSTOM CAKES & S <br /> OwnerAddress 2 F✓e-k Q X550 (LAC <br /> STOCKTON, CA-R� R 5212 <br /> Work/Business Phone Not Specified <br /> Alternative Phone 209-808-2679 <br /> Mailing Address 2523 FRED RUSSO CT <br /> STOCKTON, CA 95212 <br /> Care of ROGERS, ELWANDA <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0024540 <br /> Facility Name TEELICIOUS TREATS CUSTOM CAKES & S' <br /> Location 2 5 23 t—/eot l X55 C—� <br /> STOCKTON, CA 962M 21 2 <br /> Phone 209-808-2679 <br /> Mailing Address 2523 FRED RUSSO CT <br /> STOCKTON, CA 95212 <br /> Care of ROGERS, ELWANDA <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name ROGERS, ELWANDA <br /> Title <br /> Day Phone 209-808-2679 <br /> Night Phone 209-451-1971 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0045818 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name TEELICIOUS TREATS CUSTOM CAKES & SWEET: (Circle One) <br /> Account Balance as of 4/1/2019: $0.00 <br /> (Circle One) <br /> Transfer to Active/Inactve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1608-CLASS A COTTAGE FOOD-DIRECT SALES PR0542656 EE0004589-KADEANNE LINHARES Active Y N A I D <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 <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 Stale 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 by <br /> EHD Date�_/�_/ Account out: Date /s3/If <br /> COMMENTS: <br /> If1VOICe#: <br />