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„ Date run 5/21/2015 4:07:18PR SAN JCOUIN COUNTY ENVIRONMENTAL HEA*DEPARTMENT Report#5021 Run by Pagel Facility Information as of 5/2112015 Record Selection Criteria: Facility ID FA0013846 Make changestcorrections in RED ink. INFORMATION CHANGE(date) OWNERSHIP CHANGE(date) OWNER FILE INFORMATION Number of facilities for this owner: 20 SSN/Fed Tax ID Owner ID OW0000819 New Owner lD Owner Name Anil Yadav Owner DBA Owner Address 3550 MOWRY AVE 301 FREMONT, CA 94538 Home Phone 510-792-3393 Work/Business Phone 510-792-3393 Mailing Address 3550 Mowry Ave#301 Fremont, CA 94538 Care of FACILITY FILE INFORMATION Facility lD/CERS ID FA0013846 10184537 Facility Name JACK IN THE BOX#4300 Location 1935 W ELEVENTH ST TRACY, CA 95376 Phone 209-836-2066 Mailing Address 3550 MOWRY AVE STE#301 FREMONT, CA 94538 Care of VARRIS MANAGEMENT INC Location Code 03-TRACY Alt Phone BOS District 005 - ELLIOTT, BOB Fax APN 23217017 EMail: EMERGENCY NOTIFICATION CONTACT INFORMATION Contact Name VARRIS MANAGEMENT INC Title Day Phone 209-836-2066 Night Phone 510-792-3393 ACCOUNTS RECEIVABLE FILE INFORMATION Account ID AR0023317 New Account ID: Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account Account Name JACK IN THE BOX#4300 (Circle one) Account Balance as of 5/21/2015: $0.00 (Circle One) Transferto ActiveAnactve PrograndElement and Description Record I Employee ID and Name Status New Owner! Delete 1625-RESTAURANT/BAR 51-100 SEATS PRO518341 EE0001420-MELISSA NISSIM Active Y N A I D 1921 -HMBP-Regular-Primary Location PRO521224 EE0002474-MICHAEL PARISSI Active Y N A I D 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0519172 EE0000000-HAZ MAT SJC OES Inactive Y N A I D ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0532381 Inactive Y N A I D BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor protect speck,PHSIEHD hourly charges associated with this facility or activity will be billed to the party identified as the OWNER on this form. I also candy that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State and'or Federal Laws, APPLICANT'S SIGNATURE: Date Program Records to be TRANSFERED: '$25.00= Amount Paid Date Water System to be TRANSFERED: Amount Paid Date Payment Type Check Number Received by EHD Staff: Date / / Account out: Date COMMENTS: Invoice#: I