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Date run 6/16/2015 10:21:40AI SAT 1AQUIN COUNTY ENVIRONMENTAL VH DEPARTMENT Report#5021 <br /> Run by Na., Pagel <br /> Facility Information as of 6/16/2b15 <br /> Record Selection Criteria: Facility ID FA0012181 <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: 1 SSN/Fed Tax ID <br /> Owner ID OW0020989 New Owner ID <br /> Owner Name SCHRADER, CATHY <br /> Owner DBA <br /> OwnerAddress 4502 GEORGETOWN PL STE 100 <br /> STOCKTON, CA 95207 <br /> Home Phone Not Specified <br /> Work/Business Phone Not Specified <br /> Mailing Address 4502 GEORGETOWN PL STE 100 <br /> STOCKTON, CA 95207 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility ID/CERS ID FA0012181 10184161 <br /> Facility Name MCDONALDS#20612 <br /> Location 3355 E HAMMER LN <br /> STOCKTON, CA 95210 <br /> Phone 209-478-0234 x <br /> Mailing Address 4502 GEORGETOWN PL #100 <br /> STOCKTON, CA 95207-6255 <br /> Care of Cathy Schrader <br /> Location Code 01 -STOCKTON Alt Phone <br /> BOS District 003- BESTOLARIDES, STEVE Fax <br /> APN 12618007 EMaiI: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name SCHRADER, CRAIG <br /> Title <br /> Day Phone 209-478-0234 <br /> Night Phone 209-478-0234 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0019586 NewAccount ID: <br /> Mail Invoices to Account Mail Invoices to: Owner / Facility / Account <br /> Account Name MCDONALDS#20612 (Circle One) <br /> Account Balance as of 6/16/2015: $0.00 <br /> (Circle One) <br /> Transfer to Active.9naclve <br /> Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1625-RESTAURANT/BAR 51-100 SEATS PRO515486 EE0009488-JEFFREY WONG Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0520888 EE0000006-HAZA SAEED Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO517790 EE0000000-HAZ MAT SJC OES Inactive Y N A I D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE FI PR0517791 EE0000149-RAYMOND BORGES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARGI PRO533053 InaQive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operatoror agent of same,acknowledge that all site,andor protect specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to the party identified as the OWNER on this form. I also cer ify that all operations will be performed in accordance with all applicable Ordinance Codes andor Standards and State andor <br /> Federal Laws, <br /> APPLICANTS SIGNATURE: Date <br /> Program Records to be TRANSFERED: '$25.00= Amount Paid Date / I <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: Invoke#: <br />