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Date run 022/2008 10:47:21AI SAN JO 1UIN COUNTY ENVIRONMENTAL HEA' "3 DEPARTMENT <br /> Run by 4006 Report#5U21 <br /> Facility Information as of 91221200$ Pagel <br /> Record Selection Criteria: FacilityID FA0013846 <br /> Make changeslcorrections in RED Ink or pencil. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID OW0000133 New Owner ID <br /> Owner Name JACK IN THE BOX INC <br /> Owner DBA JACK IN THE BOX <br /> Owner Address 9330 BALBOA AVE <br /> RECEIVED- <br /> SAN DIEGO, CA 921231516 <br /> Home Phone 858-571-2529 SEP -2 3 2008 <br /> Work/BusinessPhone 858_571-2611 <br /> Mailing Address 9330 BALBOA AVE <br /> OFFICE OF EME, <br /> SAN DIEGO, CA 921231516 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID FA0013846 <br /> Facility Name JACK IN THE BOX#4300 <br /> Location 1935 W 11 TH ST <br /> TRACY, CA 95376 <br /> Phone 209-824-5359 <br /> Mailing Address 9330 BALBOA AVE <br /> SAN DIEGO, CA 921231516 <br /> Care of <br /> Location Code 03-TRACY Alt Phone <br /> BOS District 005-ORNELLAS, LEROY Fax <br /> APN 23217017 Entail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name TERESA HALE <br /> Title <br /> Day Phone 206-476-4604 <br /> Night Phone 209-574-9389 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0023317 New Account ID: : <br /> Mail Invoices to Facility Mail Invoices to: Owner 1 Facility / Account <br /> Account Name JACK IN THE BOX#4300 (circle one) <br /> Account Balance as of 912212008: $0.00 <br /> (Clyde one) <br /> Program/Element and Description Record ID Employee ID and Name Status NewTransfer to Active ve <br /> Owner/ Delete lets <br /> 1625-RESTAURANTIBAR 51-100 SEATS PRO518341 EE0001699-JOHNNY YOAKUM Active Y N A I D <br /> 2244-PACT TRANSFER RECORD-OES PR0521224 EE0000000-HAZ MAT SJC OES Active Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARIPR0519172 EE0o00000-HAZ MAT SJC IDES Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,and/or project spec.PHSIEHD hourly charges associated with this <br /> facility or activity will be billed to the party identtfied as the OWNER on this form. I also certify that all operations will be performed in accordance with all applicable Ordlnace Codes and/or Standards and <br /> State andfor Federal Laws. <br /> APPLICANT'S SIGNATURE: Date 1 I <br /> Program Records to be TRANSFERED: *$20.00= Amount Paid Date I I <br /> Water System to be TRANSFERED: '$372.00= Amount Paid Date / 1 <br /> Payment Type Check Number Received by <br /> REHS: Date 1 Jr Account out: Date I I <br /> COMMENTS: <br /> Ilnhc-phcnl-ntlannclanvicinn.clrpnnrta4rn" rnt <br />