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Date <br /> Run by Nn 8/19/2013 1:53:38PA SAN 3^WIN COUNTY ENVIRONMENTAL HEA"TH DEPARTMENT <br /> Report(15027 <br /> Facility Information as of 8/1912eb Pagel <br /> Recon Selection Criteria: Facility ID FA0007151 <br /> Make changes/corrections in RED ink. <br /> INFORMATION CHANGE(date) <br /> OWNER FILE INFORMATION OWNERSHIP CHANGE(date) <br /> SSN/Fed Tax ID <br /> Owner ID <br /> OW0016471 New Owner ID <br /> Owner Name APPLE NORCAL LLC <br /> Owner DBA APPLEBEES <br /> Owner Address 6200 OAK TREE BLVD STE 250 <br /> CLEVELAND, OH 44131 <br /> Home Phone 216-525-2775 <br /> Work/Business Phone Not Specified <br /> Mailing Address 6200 OAK TREE BLVD STE#250 <br /> CLEVELAND, OH 44131 <br /> Care of <br /> FACILITY FILE INFORMATION <br /> Facility lD/CERS ID FA0007151 10,182,211 <br /> Facility Name APPLEBEES <br /> Location 2442 W KETTLEMAN LN <br /> LODI, CA 95242 <br /> Phone 209-369-6657 <br /> Mailing Address Faf)(ip.ILTR^^ <br /> 31 tlecf `,1!2 G <br /> Care ofd, C ti tv IL( ,/1 O <br /> Location Code 02 - LODI Alt Phone <br /> BOS District 004-VOGEL, KEN Fax <br /> APN 05814042 EMail: <br /> EMERGENCY NOTIFICATION CONTACT INFORMATION <br /> Contact Name.ADAM-PtERCE Ai l <br /> Title <br /> so 3 �— 7 22 1— 2&2 <br /> Day Phi <br /> Night Phone 216-525-2713 <br /> ACCOUNTS RECEIVABLE FILE INFORMATION <br /> Account ID AR0010377 New Account ID: <br /> Mail Invoices to Facility Mail Invoices to: Owner / Facility / Account <br /> Account Name APPLEBEES (CPcleOne) <br /> Account Balance as of 8/19/2013: $0.00 <br /> (Circle One) <br /> Transferto ActivellnacNe <br /> PrograMElement and Description Record ID Employee ID and Name Status New Owner? Delete <br /> 1626-RESTAURANT/BAR 101 +SEATS PRO506023 EE0005362-NICHOLAS WIESEMAN Active Y N A I D <br /> 1921 -HMBP-Regular-Primary Location PR0520727 EE0008709-JAMIE DE LA ROSA Active Y N A I D <br /> 2224-HAZ MAT BUSINESS PLAN AUTHORIZATION PRO513469 EE0000000-HAZ MAT SJC OES Inactive Y N A 1 D <br /> 2399-UNIFIED PROGRAM FAC STATE SURCHARGE F PR0511181 EE0000000-HAZ MAT SJC DES Inactive Y N A I D <br /> ERSC-ELECTRONIC REPORTING STATE SURCHARG PR0535267 Inactive Y N A I D <br /> BILLING and COMPLIANCE ACKNOWLEDGEMENT: I,the undersigned owner,operator or agent of same,acknowledge that all site,andor project specific,PHSIEHD hourly charges associated with this facility <br /> or activity will be billed to Ne party identified as the OWNER on this form I also certify that all operations will be performed in accordance with all applicable Ordnance Codes ander Standards and State ander <br /> Federal Laws. <br /> APPLICANT'S 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 Rec ' e bv <br /> REHS: Date_�/ /,� Account out: Date 113 <br /> COMMENTS:COMMENTS: <br /> lj*�? VtAA,+ we6 L: <br />