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Date run 7/1/2015 8:11:33AM SAN JOAQUIN COUNTY' ENVIRONMENTAL HEALTH DEPARTMENT Report#5021 <br />Run by Pagel <br />Facility Information as of 7/1/2015 <br />Record Selection Criteria: Facility ID FA0016635 <br />OWNER FILE INFORMATION Number of facilities for this owner: 1 <br />Owner ID <br />OW0013480 <br />Owner Name <br />MANTECA STAR LLC <br />Owner DBA <br />CARL'S JR <br />Owner Address <br />3225 PLANTATION CT <br />MODESTO, CA 953558717 <br />Home Phone <br />209-551-1993 <br />Work/Business Phone <br />209-825-7190 <br />Mailing Address <br />899 CHERRY AVE <br />SAN BRUNO, CA 94066 <br />Care of <br />HERNANDEZ, V EMILIO <br />FACILITY FILE INFORMATION <br />Facility ID / CERS ID <br />FA0016635 <br />Facility Name <br />CAR LS JR #1575 <br />Location <br />1489 HULSEY WAY <br />MANTECA, CA 95336 <br />Phone <br />209-825-7190 <br />Mailing Address <br />899 CHERRY AVE <br />SAN BRUNO, CA 94066 <br />Care of <br />MANTECA STAR LLC <br />Location Code <br />04 - MANTECA <br />Bos District <br />005 - ELLIOTT, BOB <br />APN <br />EMERGENCY NOTIFICATION CONTACT INFORMATION <br />Contact Name <br />MANTECA STAR LLC <br />Title <br />Day Phone <br />209-825-7190 <br />Night Phone <br />209-551-1993 <br />ACCOUNTS RECEIVABLE FILE INFORMATION <br />Account ID AR0029427 <br />Mail Invoices to Facility <br />Account Name CARLS JR #1575 <br />Account Balance as of 7/1/2015: $0.00 <br />Make changes/corrections in RED ink. <br />INFORMATION CHANGE (date) <br />OWNERSHIP CHANGE (date) <br />SSN / Fed Tax ID <br />New Owner ID : <br />Alt Phone <br />Fax <br />EMail : <br />Mail Invoices to: <br />New Account ID: : <br />Owner / Facility / Account <br />(Circle One) <br />(Circle One) <br />Transfer to Active/Inactve <br />Program/Element and Description Record ID Employee ID and Name Status New Owner? Delete <br />1625 - RESTAURANT/BAR 51-100 SEATS PR0524777 EE0004589 - KADEANNE LINHARES Active Y N A I D <br />BILLING and COMPLIANCE ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site, andror 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 anrllor Standards and State and/or <br />Federal Laws. <br />APPLICANT'S SIGNATURE: <br />Program Records to be TRANSFERED: <br />Water System to be TRANSFERED: <br />Payment Type Check Number <br />EHD Staff: <br />COMMENTS: <br />$25.00 = <br />Date <br />Date <br />Amount Paid Date <br />_ Amount Paid Date <br />Received by <br />Account out: Date <br />Invoice #: <br />