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Date run 5/22/2015 8:27:28AR SAN JUIN COUNTY ENVIRONMENTAL HE*DEPARTMENT Report#5021 <br /> Pagel <br /> Run by Facility Information as of 5/22/2015 <br /> Record selection Criteria: Facility ID FA0006595 <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: 4 SSN/Fed Tax ID <br /> Owner ID OW0005335 New Owner ID <br /> Owner Name IN N OUT BURGER INC <br /> Owner DBA <br /> Owner Address 13502 HAMBURGER LN <br /> BALDWIN PARK, CA 91706 <br /> Home Phone 626-813-8200 <br /> WorkBusiness Phone 949-509-6300 <br /> Mailing Address 4199 Campus Drive <br /> Irvine, CA 92612 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0006595 10182123 <br /> Facility Name IN N OUT BURGER#96 <br /> Location 575 W CLOVER RD <br /> TRACY, CA 95376 <br /> Phone 949-509-6200 x <br /> Mailing Address 4199 CAMPUS DR 9TH FLOOR <br /> IRVINE, CA 92612 <br /> Care of IN-N-OUT BURGER Inc. <br /> Location Code 03 -TRACY Alt Phone <br /> SOS District 005 - ELLIOTT, BOB Fax <br /> APN 21421006 EMail. <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name IN N OUT BURGER INC <br /> Title <br /> Day Phone 209-833-3569 <br /> Night Phone 209-833-3569 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0008870 New Account ID: <br /> Mail Invoices to: Owner / Facility / Account <br /> Mail Invoices to Account <br /> circle One) <br /> Account Name IN N OUT BURGER#96 <br /> Account Balance as of 5/22/2015: $0.00 (Circle one) <br /> Transfer to ActivelinacNe <br /> PrograMElemenl and Description <br /> Record ID Employee ID and Name Status New Owner? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PR0505178 EE0001420-MELISSA NISSIM Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0520672 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO613393 EE0000000-HAZ MAT SJC IDES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PRO511105 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO632535 Inactive 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 specrfic,PHSfEHD hourly charges associated with this facility <br /> or activity will be billed to me party iderniged 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 State andror <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 Staff: Date_/_/_ Account out: Date <br /> COMMENTS: Invoice M <br />