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Date ran 5/21/2015 4:25:55PA SAN JUIN COUNTY ENVIRONMENTAL HE DEPARTMENT <br /> Report#5021 <br /> Run by Pagel <br /> Facility Information as of 5/21/2015 <br /> Record Selection Criteria: Facility ID FA0003191 <br /> Make changeslcorrections 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 OW0000762 New Owner ID <br /> Owner Name WENDYS OF THE PACIFIC <br /> Owner DBA WENDYS OF THE PACIFIC <br /> Owner Address 1308 KANSAS AVE 6 <br /> MODESTO, CA 953511530 <br /> Home Phone 209-577-6690 <br /> Work/Business Phone 209-577-6690 <br /> Mailing Address 1308 KANSAS AVE STE STE 6 <br /> MODESTO, CA 95351-1530 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0003191 10181069 <br /> Facility Name WENDYS#20 (CLOVER) <br /> Location 725 W CLOVER RD'N <br /> Tracy, CA 95376 <br /> Phone 209-836-3346 x <br /> Mailing Address 1308 KANSAS AVE STE 6 <br /> MODESTO, CA 95351-1530 <br /> Care of WENDYS OF THE PACIFIC <br /> Location Code 03 -TRACY Alt Phone <br /> BOS District 005- ELLIOTT, BOB Fax <br /> APN 21418019 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name WENDYS OF THE PACIFIC <br /> Title <br /> Day Phone 209-836-3346 <br /> Night Phone 209-836-3346 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0002759 New Account ID: <br /> Maillnvoicesto Owner Mail Invoices to: Owner / Facility / Account <br /> Account Name WENDYS OF THE PACIFIC (Circle One) <br /> Account Balance as of 5/21/2015: $0.00 <br /> (Circle One) <br /> Transferto Active/Inicive <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO161132 EE0001420-MELISSA NISSIM Active Y N A I D <br /> 1921 -HMSP-Regular-Primary Location PRO520749 EE0002474-MICHAEL PARISSI Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513493 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0511205 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PRO534298 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT. Lure undersigned owner,operator or agent of same,acknowledge that all site,anNor 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 anNor Standards and State 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 Staff: Date /_/_ Account out: Date_/_/ <br /> COMMENTS: Invoice#: <br />