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Date run 10/14/2015 2:38:45F SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 10/14/2015 <br />Record Selection Criteria: Facility ID FA0022860 <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 <br />OW0020835 New Owner ID <br />Owner Name <br />EDGINGTON, WILLIAM J <br />Owner DBA <br />GYPSY SOUL TATTOO <br />OwnerAddress <br />1568 FRENCH CAMP RD <br />MANTECA, CA 95336 <br />Home Phone <br />209-204-9925 <br />Work/Business Phone <br />Not Specified <br />Mailing Address <br />1568 FRENCH CAMP RD <br />MANTECA, CA 95336 <br />Care of <br />EDGINGTON, WILLIAM J <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0022860 <br />Facility Name <br />GYPSY SOUL TATTOO (WILLIAM EDGINGT, <br />Location <br />118 W YOSEMITE AVE <br />MANTECA, CA 95336 <br />Phone <br />209-239-0800 <br />Mailing Address <br />118 W YOSEMITE AVE <br />MANTECA, CA 95336 <br />Care of <br />EDGINGTON, WILLIAM J <br />Location Code <br />04 - MANTECA Alt Phone <br />BOS District <br />Fax <br />APN <br />EMail : <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />EDGINGTON, WILLIAM J <br />Title <br />Day Phone <br />209-239-0800 <br />Night Phone <br />209-204-9925 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0041930 <br />Mail Invoices to Facility Mail Invoices to: <br />Account Name GYPSY SOUL TATTOO (WILLIAM EDGINGTON) <br />Account Balance as of 10/14/2015: $0.00 <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />4110 - BODY ART PRACTITIONER REGISTRATION PR0540005 EE0003973 - ROBERT MCCLELLON Active Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andror 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 andlor Standards and State andlor <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: <br />COMMENTS: <br />s <br />$25.00 = <br />Date <br />Amount Paid Date <br />Amount Paid Date <br />Received by <br />Date / / Account out: Date <br />Invoice #: <br />0 <br />