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Dale run 7/24/2017 2:27:46PK SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br /> Run by Pagel <br /> Facility Information as of 7/24/2017 <br /> Record Selection Criteria: Facility ID FA0001886 <br /> Make changesicorrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNERSHIP CHANGE(date) <br /> OWNER FILE INFORMATION Number of facilities for this owner: 1 SSN/Fed Tax ID <br /> Owner ID OW0006094 New Owner ID <br /> Owner Name Conley 206, Inc. <br /> Owner DBA KFC HARMAN-CONLEY <br /> Owner Address 5544 GREEN ST <br /> SALT LAKE CITY, UT 841235798 <br /> Home Phone Not Specified <br /> Work/Business Phone 916-553-2267 <br /> Mailing Address 1555 Meadovil Road, Suite 150 <br /> Sacramento, CA 95823 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0001886 10180827 <br /> Facility Name KENTUCKY FRIED CHICKEN#206 <br /> Location 3264 W HAMMER LN <br /> STOCKTON, CA 95209-2737 <br /> Phone 209-478-5754 x <br /> Mailing Address 1555 Meadowview Road, Suite 150 <br /> Sacramento, CA 95823 <br /> Care of Conley 206, Inc. <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 002- MILLER, KATHERINE Fax <br /> APN EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name FONG, HAZEL <br /> Title <br /> Day Phone 916-689-2190 xSAC RE <br /> Night Phone 510-429-7925 xBAY RE <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0001893 New Account ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name Conley 206, Inc. (CiroleOne) <br /> Account Balance as of 7/24/2017: $342.00 <br /> (Circle One) <br /> Transfer to Activellm lve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner! Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO162840 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> 1919-HMBP-CO2 Only Food Facilifv PRO520988 EE0006213-VIDAL PEDRAZA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO517651 EE0000000-HAZ MAT SJC OES nac IvE Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0517654 EE0001699-JOHNNY YOAKUM Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0533904 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,ander project specific,PHSEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this forth. I also minify that all operations will be performed in accordance with all applicable Ordinance Codes andfor Standards and State shelter <br /> Federal Laws. <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date <br /> Water System to be TRANSFERED: Amount Paid Date_/ I <br /> Payment Type Check Number Received by <br /> EHD Staff: Date_I / Account out: Date <br /> COMMENTS: Invoice ff: <br />