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Date run 10/30/2013 11:04:31/ SAN JOIN COUNTY ENVIRONMENTAL HEA1f DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 10/30/2013 <br /> Record Selection Criteria: Facility ID FA0002577 <br /> Make changestcorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(dale) <br /> OWNER FILE INFORMATION SSN/Fed Tax ID <br /> Owner ID OW0000819 New Owner ID <br /> Owner Name YADAV, ANIL <br /> Owner DBA <br /> Owner Address 3550 MOWRY AVE STE 301 <br /> FREMONT, CA 94538 <br /> Home Phone 510-792-3393 <br /> Work/Business Phone 510-792-3350 <br /> Mailing Address 3550 MOWRY AVE STE#301 <br /> FREMONT, CA 94538 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0002577 10,180,969 <br /> Facility Name JACK IN THE BOX <br /> Location 733 W CHARTER WAY <br /> STOCKTON, CA 95206 <br /> Phone 209-640-1298 <br /> Mailing Address 3550 MOWRY AVE STE#301 <br /> FREMONT, CA 94538 <br /> Care of ANILYADAV <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 001 -VILLAPUDUA Fax <br /> APN 16323036 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name ANILYADAV <br /> Title <br /> Day Phone 209-640-1298 <br /> Night Phone 510-792-3393 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0004756 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name JACK IN THE BOX (Circle One) <br /> Account Balance as of 10/30/2013: $0.00 <br /> (Circle One) <br /> Transfer to Activellnactte <br /> PrograrrVElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PR0160827- EE0003361 -MARIBEL FLOHRSCHUTZ Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PRO626525 EE000981.7-ROBERT LOPEZ Active Y N A 1 D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO632041 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. I.me undersigned owner,operator or agent of same,acknowledge that all site,ander project specific,PMS/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 parfomred in accordance with W applicable Ordinance Codes andor Standards and State andor <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 /> REHS: Date_/ / Account out: Date <br /> COMMENTS: <br />